Publications by authors named "Takeshi Kitamura"

95 Publications

Persistent atrial fibrillation ablation in cardiac laminopathy: Electrophysiological findings and clinical outcomes.

Heart Rhythm 2021 Mar 31. Epub 2021 Mar 31.

Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux-Pessac, France. Electronic address:

Background: Little is known about persistent atrial fibrillation (AF) ablation in patients with cardiac laminopathy (CLMNA).

Objectives: We aimed to characterize atrial electrophysiological properties and to assess the long-term outcomes of persistent AF ablation in patients with CLMNA.

Methods: All patients with CLMNA referred in our center for persistent AF ablation were retrospectively included. Left atrial (LA) volume, left atrial appendage (LAA) cycle length, interatrial conduction delay, and LA voltage amplitude were analyzed during the ablation procedure. Sinus rhythm maintenance and LA contractile function were assessed during long-term follow-up.

Results: From 2011 to 2020, 8 patients were included (mean age 47 ± 14 years; 3 women). The LA volume was 205.8 ± 43.7 mL; the LAA AF cycle length was 250.7 ± 85.6 ms; and the interatrial conduction delay was 296.5 ± 110.1 ms. Large low-voltage areas (>50% of the LA surface; <0.5 mV electrogram) were recorded in all 8 patients. Two patients had inadvertent LAA disconnection during ablation. All A waves recorded by pulsed Doppler in sinus rhythm were <30 cm/s before and after AF ablation. Early arrhythmia recurrence was recorded in 7 patients (87%) (time to recurrence 4 ± 4 months; 1.5 procedures per patient). After a mean follow-up of 4.4 ± 3.2 years, 4 patients underwent implantable cardioverter-defibrillator therapy for life-threatening ventricular arrhythmia and 3 patients finally underwent heart transplantation.

Conclusion: Patients with persistent AF afflicted by CLMNA exhibit severe LA impairment because of large low-voltage areas, prolonged conduction velocity, and reduced contractile function. Ablation procedures have a limited effect with a high recurrence rate.
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http://dx.doi.org/10.1016/j.hrthm.2021.03.040DOI Listing
March 2021

Cardiac perforation due to a fracture of a recalled Accufix bipolar active fixation pacing lead 29 years after implantation: A case report.

J Cardiovasc Electrophysiol 2021 Mar 30. Epub 2021 Mar 30.

Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan.

The Accufix bipolar active fixation atrial pacing lead (Model 330-801; Telectronics) can have mechanical complications due to a fracture of its J retention wire. An 80-year-old man had the Accufix atrial pacing lead implanted 29 years prior, and surgical removal was required because a part of the lead was perforating the apex of the right ventricle. Regular follow-up examinations are recommended to eliminate the possibility of protrusion and detachment of the J retention wire, even if the clinical course after implantation is stable for a prolonged period.
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http://dx.doi.org/10.1111/jce.15024DOI Listing
March 2021

Ligament of Marshall ablation for persistent atrial fibrillation.

Pacing Clin Electrophysiol 2021 May 5;44(5):782-791. Epub 2021 Apr 5.

LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France.

Beyond pulmonary vein isolation, the two main additional strategies: Cox-Maze procedure or targeting of electrical signatures (focal bursts, rotational activities, meandering wavelets), remain controversial. High-density mapping of these arrhythmias has demonstrated firstly that a patchy lesion set is highly proarrhythmogenic, favoring macro-re-entry through conduction slowing and providing pivots for localized re-entry. Secondly, discrete anatomical structures such as the Vein or Ligament of Marshall (VOM/LOM) and the coronary sinus (CS) have epicardial muscular bundles that are more frequently involved in re-entry than previously thought. The Marshall Bundle can be ablated at any point along its course from the mid-to-distal coronary sinus to the left atrial appendage. If necessary, the VOM may be directly ablated using ethanol infusion to eliminate PV contributions and produce conduction block across the mistral isthmus. Ethanol ablation of the VOM, supplemented with RF ablation, may be more effective in producing conduction block at the mitral isthmus than repeat RF ablation alone.
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http://dx.doi.org/10.1111/pace.14208DOI Listing
May 2021

Use of high-density activation and voltage mapping in combination with entrainment to delineate gap-related atrial tachycardias post atrial fibrillation ablation.

Europace 2021 Feb 10. Epub 2021 Feb 10.

Electrophysiology and Ablation Unit, Hôpital Cardiologique du Haut Lévêque, Avenue de Magellan, 33604 Pessac Cedex, France.

Aims: An incomplete understanding of the mechanism of atrial tachycardia (AT) is a major determinant of ablation failure. We systematically evaluated the mechanisms of AT using ultra-high-resolution mapping in a large cohort of patients.

Methods And Results: We included 107 consecutive patients (mean age: 65.7 ± 9.2 years, males: 81 patients) with documented endocardial gap-related AT after left atrial ablation for persistent atrial fibrillation (AF). We analysed the mechanism of 134 AT (94 macro-re-entries and 40 localized re-entries) using high-resolution activation mapping in combination with high-density voltage and entrainment mapping. Voltage in the conducting channels may be extremely low, even <0.1 mV (0.14 ± 0.095 mV, 51 of 134 AT, 41%), and almost always <0.5 mV (0.03-0.5 mV, 133 of 134 AT, 99.3%). The use of multipolar Orion, HDGrid, and Pentaray catheters improved our accuracy in delineating ultra-low-voltage areas critical for maintenance of the circuit of endocardial gap-related AT. Conventional ablation catheters often do not detect any signal (noise level) even using adequate contact force, and only multipolar catheters of small electrodes and shorter interelectrode space can detect clear fractionated low-amplitude and high frequency signals, critical for re-entry maintenance. We performed a diagnosis in 112 out of 134 AT (83.6%) using only activation mapping and in 134 out of 134 AT (100%) using the combination of activation and entrainment mapping.

Conclusion : High-resolution activation mapping in combination with high-density voltage and entrainment mapping is the ideal strategy to delineate the critical part of the circuit in endocardial gap-related re-entrant AT after AF ablation.
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http://dx.doi.org/10.1093/europace/euaa394DOI Listing
February 2021

The effect of posterior wall isolation for persistent atrial fibrillation on recurrent arrhythmia.

J Cardiovasc Electrophysiol 2021 Mar 2;32(3):597-604. Epub 2021 Feb 2.

Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan.

Introduction: It is important to consider recurrent arrhythmia after catheter ablation for persistent atrial fibrillation (AF) for planning an ablation strategy. However, the studies are limited to pulmonary vein isolation (PVI) plus posterior wall isolation (PWI), which were reported to improve procedural outcomes. The objective of this study is to evaluate the effect of PWI on recurrent arrhythmia.

Methods: This is an observational study on patients with persistent AF comparing PVI plus PWI and PVI only strategies. In PVI plus PWI group, linear ablation of the left atrium roofline and bottom line were performed to achieve PWI after PVI. Some patients with AF recurrence underwent the second procedure. The presence of recurrent arrhythmia and results of the second procedures were evaluated.

Results: A total of 181 patients (mean age, 66.9 ± 10.2 years; male, 76.8%) were included. PVI plus PWI group and PVI only group consisted of 90 and 91 patients, respectively. AF recurrence was observed in 28 of 90 (31.1%) patients with PVI plus PWI and in 43 of 91 (47.3%) with PVI only, and log-rank test did not show any significant difference (p = .35). The occurrence of recurrent persistent AF was significantly lower in PVI plus PWI group than in PVI only group (5/90; 5.6% vs. 18/91; 20.9%, p = .002). There was no significant difference between the two groups in recurrent paroxysmal AF and atrial tachycardia (AT).

Conclusion: PWI, in addition to PVI, for persistent AF was significantly related to fewer episodes of recurrent persistent AF, and it did not increase recurrent AT.
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http://dx.doi.org/10.1111/jce.14906DOI Listing
March 2021

Ultralow temperature cryoablation: Safety and efficacy of preclinical atrial and ventricular lesions.

J Cardiovasc Electrophysiol 2021 Mar 1;32(3):570-577. Epub 2021 Feb 1.

IHU LIRYC ANR-10-IAHU-04, Electrophysiology and Heart Modeling Institute, University of Bordeaux, Bordeaux-Pessac, France.

Background: Ultralow temperature cyroablation (ULTC) is designed to create focal, linear, and circumferential lesions. The aim of this study was to assess the safety, efficacy, and durability of atrial and ventricular ULTC lesions in preclinical large animal models.

Methods And Results: The ULTC system uses nitrogen near its liquid-vapor critical point to cool 11-cm ablation catheters. The catheter can be shaped to specific anatomies using pre-shaped stylets. ULTC was used in 11 swine and four sheep to create atrial (pulmonary vein isolation and linear ablation) and ventricular lesions. Acute and 90-day success were evaluated by intracardiac mapping and histologic examination. Cryoadherence was observed during all ULTC applications, ensuring catheter stability at target locations. Local electrograms were completely eliminated immediately after the first single-shot ULTC application in 49 of 53 (92.5%) atrial and in 31 of 32 (96.9%) ventricular applications. Lesion depth as measured on histology preparations was 1.96 ± 0.8 mm in atrial and 5.61 ± 2.2 mm in ventricular lesions. In all animals, voltage maps and histology demonstrated transmural and durable lesions without gaps, surrounded by intact collagen fibers without injury to surrounding tissues. Transient coronary spasm could be provoked with endocardial ULTC in the left ventricle in close proximity to a coronary artery.

Conclusions: ULTC created effective and efficient atrial and ventricular lesions in vivo without procedural complications in two large animal models. ULTC lesions were transmural, contiguous, and durable over 3 months.
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http://dx.doi.org/10.1111/jce.14907DOI Listing
March 2021

Safety and effectiveness of intracardiac echocardiography in ventricular tachycardia ablation: a nationwide observational study.

Heart Vessels 2021 Jan 21. Epub 2021 Jan 21.

Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.

Intracardiac echocardiography (ICE) utilized in conjunction with three-dimensional (3-D) mapping systems could enhance ventricular tachycardia (VT) ablation procedures. ICE has been increasingly used in VT ablation; however, the safety and effectiveness of VT ablation under the combined use of ICE remains unclear. The present study aimed to analyze the safety and short-term effects of VT ablation with or without ICE. We retrospectively enrolled patients who underwent initial VT ablation with a combination of ICE and a 3-D mapping system within 3 days of hospitalization and discharged from April 2011 to March 2017 using a nationwide Japanese inpatient database. Following enrollment, we conducted a propensity score-matching analysis to compare safety (in-hospital complications) and effectiveness (readmission within 30 days after discharge due to cardiovascular disease and readmissions within 30 days for repeat VT ablations) between patients who underwent VT ablation with (ICE group) and without ICE (non-ICE group). 3-D mapping systems were applied to both groups. We identified 5,804 eligible patients (1,272 and 4,532 patients in the ICE and non-ICE groups, respectively). One-to-one propensity score matching created a total of 1,147 pairs between the ICE and non-ICE groups. The ICE group showed a significantly lower prevalence of cardiac tamponade than the non-ICE group. There were no significant differences observed between the two groups regarding other outcomes concerning safety and effectiveness. Ventricular tachycardia ablation with ICE used in combination with a 3-D mapping system may reduce cardiac tamponade; however, no additional clinical advantages were noted in terms of safety and effectiveness.
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http://dx.doi.org/10.1007/s00380-020-01766-yDOI Listing
January 2021

A new method of superior vena cava isolation without phrenic nerve injury by longitudinal ablation parallel to the phrenic nerve: a case report.

Eur Heart J Case Rep 2020 Oct 9;4(5):1-4. Epub 2020 Sep 9.

Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, 2-34-10, Ebisu, Shibuya-ku, Tokyo 150-0013, Japan.

Background: Superior vena cava (SVC) isolation has improved the outcomes of paroxysmal atrial fibrillation (AF) originating from the SVC. However, right phrenic nerve (PN) injury is a major complication of this procedure. Therefore, in cases where the right atrium (RA)-SVC conduction site is near the PN, tremendous care is required to prevent PN injury.

Case Summary: Repeated SVC isolation was performed due to the recurrence of SVC-triggered AF. The RA-SVC activation map revealed that the partial conduction block line was detected, and the propagation broke through the gap at the course of the PN site from the RA to the SVC. Since the course of the PN identified at high-output pacing was wide, the SVC was isolated by making longitudinal lines on both sides of the PN in a cranial direction, except for where low-output pacing captured, confirming compound muscle action potential to detect PN injury. Eventually, the SVC was successfully isolated without PN injury, and the sinus rhythm was maintained without antiarrhythmic drugs during a 14-month follow-up period.

Conclusion: Superior vena cava isolation was difficult depending on the course of the PN, and some methods to avoid PN injury were reported. However, this method can facilitate safe and effective SVC isolation with the conventional system, including the cases with AF foci located on the course of the PN.
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http://dx.doi.org/10.1093/ehjcr/ytaa312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7780490PMC
October 2020

Marshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation (Marshall-PLAN): Prospective, single-center study.

Heart Rhythm 2021 Apr 29;18(4):529-537. Epub 2020 Dec 29.

IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; Bordeaux University Hospital (CHU), Cardio-Thoracic Unit, Pessac, France.

Background: Beyond pulmonary vein isolation (PVI), the optimal ablation strategy for persistent atrial fibrillation (AF) remains poorly defined.

Objective: The purpose of this study was to examine a novel comprehensive ablation strategy (Marshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation [Marshall-PLAN]) strictly based on anatomical considerations.

Methods: Left atrial (LA) sites were sequentially targeted as follows: (1) coronary sinus and vein of Marshall (CS-VOM) musculature; (2) PVI; and (3) anatomical isthmuses (mitral, roof, and cavotricuspid isthmus [CTI]). The primary endpoint was 12-month freedom from AF/atrial tachycardia (AT).

Results: Seventy-five consecutive patients were included (age 61 ± 9 years; 10 women; AF duration 9 ± 11 months; mean LA volume 197 ± 43 mL). VOM ethanol infusion was completed in 69 patients (92%). The full Marshall-PLAN lesion set (VOM, PVI, mitral, roof, and CTI with block) was successfully completed in 68 patients (91%). At 12 months, 54 of 75 patients (72%) were free from AF/AT after a single procedure (no antiarrhythmic drugs) in the overall cohort. In the subset of patients with a complete Marshall-PLAN lesion set (n = 68), the single procedure success rate was 79%. After 1 or 2 procedures, 67 of 75 patients (89%) remained free from AF/AT (no antiarrhythmic drugs). After 1 or 2 procedures, VOM ethanol infusion was complete in 72 of 75 patients (96%).

Conclusion: A novel ablation strategy that systematically targets anatomical atrial structures (VOM ethanol infusion, PVI, and prespecified linear lesions) is feasible, safe, and associated with a high rate of freedom from arrhythmia recurrence at 12 months in patients with persistent AF.
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http://dx.doi.org/10.1016/j.hrthm.2020.12.023DOI Listing
April 2021

Novel Diagnostic Observations of Nodoventricular/Nodofascicular Pathway-Related Orthodromic Reciprocating Tachycardia Differentiating From Atrioventricular Nodal Re-Entrant Tachycardia.

JACC Clin Electrophysiol 2020 12 30;6(14):1797-1807. Epub 2020 Sep 30.

Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ibaraki, Tokyo, Japan.

Objectives: This study sought to assess the performance of current diagnostic criteria and identify additional electrophysiological features differentiating orthodromic reciprocating tachycardia (ORT) with a concealed nodoventricular/nodofascicular (NV/NF) pathway from atrioventricular nodal re-entrant tachycardia (AVNRT).

Background: Diagnosing sustained supraventricular tachycardia (SVT) despite the occurrence of ventriculoatrial block (VAB) is challenging.

Methods: We analyzed electrograms of 25 sustained SVTs (9 NV/NF-ORTs [n = 7/2] and 16 AVNRTs) with VAB and 91 AVNRTs without VAB (for reference).

Results: More than 1 SVT, each with a different ventriculoatrial interval, was commonly induced in AVNRT cases (75%) but not in NV/NF-ORT cases (0%; p = 0.0005). Wenckebach VAB was common in NV/NF-ORTs (78%), but VAB patterns varied in AVNRTs. The His-His interval transiently prolonged in the following beat after the VAB in most AVNRTs but rarely did in NV/NF-ORTs (79% vs. 22%; p = 0.01). NV/NF-ORT was diagnosed by His-refractory premature ventricular contractions (n = 5) and the findings during right ventricular overdrive pacing showing an uncorrected/corrected post-pacing interval (PPI)-tachycardia cycle length (TCL) ≤115/110 ms (n = 5/5), orthodromic His capture (n = 6), and V-V-A (ventricle-ventricle-atrial response) response (n = 3). A single form of induced SVT (positive predictive value [PPV]: 69%; negative predictive value [NPV]: 100%), Wenckebach VAB (PPV: 70%; NPV: 87%), stable His-His interval despite VAB (PPV: 70%; NPV: 85%), orthodromic His capture (PPV: 100%; NPV: 97%), and V-V-A response (PPV: 100%; NPV: 95%) characterized NV/NF-ORT, and a PPI-TCL of ≤125 ms (PPV: 100%; NPV: 100%) characterized NV-ORT.

Conclusions: Induction of a single SVT form, Wenckebach VAB, stable His-His interval despite VAB, orthodromic His capture, and V-V-A response appeared to discriminate NV/NF-ORT from AVNRT, with a PPI-TCL of ≤125 ms discriminating NV-ORT from NF-ORT and AVNRT.
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http://dx.doi.org/10.1016/j.jacep.2020.07.007DOI Listing
December 2020

The coronary artery calcium score correlates with left atrial low-voltage area: Sex differences.

J Cardiovasc Electrophysiol 2021 Jan 29;32(1):41-48. Epub 2020 Nov 29.

Tokyo Medical and Dental University, Tokyo, Japan.

Introduction: In patients with coronary artery disease, a high coronary artery calcium score (CACS) correlates with atrial fibrillation (AF); however, the association between left atrial (LA) remodeling progression and coronary arteriosclerosis is unclear. This study aimed to evaluate the relationship between LA remodeling progression and the CACS.

Methods: This retrospective study enrolled 148 patients with AF (paroxysmal AF, n = 94) who underwent catheter ablation. Voltage mapping for the left atrium and coronary computed tomography for CACS calculations were performed. The ratio of the LA low-voltage area (LA-LVA), defined by values less than 0.5 mV divided by the total LA surface without pulmonary veins, was calculated. Patients with LA-LVA (<0.5 mV) >5% and ≤5% were classified as the LVA (n = 30) and non-LVA (n = 118) groups, respectively. Patient characteristics and CACS values were compared between the two groups.

Results: LA volume, age, CHA DS VASc score, and percentage of female patients were significantly higher, and the estimated glomerular filtration rate was lower in the LVA group than in the non-LVA group. The CACS was significantly higher in the LVA group (248.4 vs. 13.2; p = .001). Multivariate analysis identified the LA volume index and CACS as independent predictors of LA-LVA (<0.5 mV) greater than 5%. The areas under the receiver operating characteristic curves for predicting LA-LVA (<0.5 mV) greater than 5% with CACS were 0.695 in the entire population, 0.782 in men, and 0.587 in women.

Conclusion: Progression of LA remodeling and coronary artery calcification may occur in parallel. A high CACS may indicate advanced LA remodeling, especially in men.
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http://dx.doi.org/10.1111/jce.14822DOI Listing
January 2021

Impact of Vein of Marshall Ethanol Infusion on Mitral Isthmus Block: Efficacy and Durability.

Circ Arrhythm Electrophysiol 2020 12 16;13(12):e008884. Epub 2020 Nov 16.

Bordeaux University Hospital (CHU), Cardiac Electrophysiology and Cardiac Stimulation Team, CHU Bordeaux, IHU Lyric, Université de Bordeaux, France (T.N., T.P., K.V., C.G., C.A., P.K., F.D.R., T. Kamakura, T.T., Y.N., T. Kitamura, M.T., G.C., R.T., R.C., N.W., J.D., F.S., H.C., M. Hocini, M. Haïssaguerre, P.J., N.D.).

Background: Achieving bidirectional mitral isthmus (MI) block using radiofrequency catheter ablation (RFCA) alone is challenging, and MI reconnection is common. Adjunctive vein of Marshall (VOM) ethanol infusion (VOM-Et) can facilitate acute MI block. However, little is known about its long-term success. This study sought to evaluate the impact of adjunctive VOM-Et on MI block achievement and durability compared with RFCA alone.

Methods: Patients undergoing the first attempt of posterior MI ablation were grouped according to their MI block index strategy: adjunctive VOM-Et and RFCA alone. Rates of acute MI block and MI reconnection observed during repeat procedures were compared between the 2 groups.

Results: The VOM-Et group consisted of 152 patients (63.8±9.4 years) undergoing adjunctive VOM-Et for MI block. The RFCA group consisted of 110 patients (60.9±9.2 years) undergoing MI ablation using RFCA alone. Acute MI block was more frequently achieved in the VOM-Et group (98.7% [150/152] versus 63.6% [70/110]; <0.001) with shorter RFCA duration (5.00 [3.00-7.00] versus 19.0 [13.6-22.0] minutes; <0.001). Of the 220 patients with MI block achieved during the index procedure, 81 underwent a repeat procedure during follow-up (VOM-Et group: 23.3% [35/150] versus RFCA group: 65.7% [46/70], respectively; <0.001). A significantly greater number of patients exhibited durable MI block in the VOM-Et group (62.9% [22/35] versus 32.6% [15/46], respectively; =0.008).

Conclusions: Beyond facilitating acute MI block, VOM-Et is associated with greater lesion durability as evidenced by higher rates of MI block during repeat procedures.
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http://dx.doi.org/10.1161/CIRCEP.120.008884DOI Listing
December 2020

Epicardial course of the septopulmonary bundle: Anatomical considerations and clinical implications for roof line completion.

Heart Rhythm 2021 Mar 11;18(3):349-357. Epub 2020 Nov 11.

Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France.

Background: Gaps in the roof line have been ascribed to epicardial conduction using the septopulmonary bundle.

Objectives: We sought to evaluate the frequency of septopulmonary bundle bypass during roof line ablation, to describe anatomical conditions favoring this epicardial gap, and to propose an alternative strategy when present.

Methods: One hundred consecutive patients underwent atrial fibrillation ablation. A de novo roof line was created between the superior pulmonary veins. In cases of residual gaps, a floor line was created between the inferior pulmonary veins. Microtomography imaging and histological analyses of 5 human donor hearts were performed: a specific focus was made on the dome and the posterior wall.

Results: Residual gaps were more frequent in roof lines than floor lines (33% vs 15%; P = .049). Electrogram morphologies, activation sequences, and pacing maneuvers indicated an epicardial bypass of the roof line in all cases. Conduction block was obtained in 67 roof lines and 28 floor lines, resulting in a 95% success rate of linear block, without "box" isolation. Between the superior pulmonary veins, the atrial myocardium was thicker and consistently displayed adipose tissue separating the septopulmonary bundle from the septoatrial bundle.

Conclusion: Epicardial conduction across the roof line is common and requires careful electrogram analysis to detect. In such cases, a floor line can be an effective alternative strategy, with clear validation criteria. Myocardial thickness and fat interposition may explain difficulties in achieving lesion transmurality during roof line ablation.
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http://dx.doi.org/10.1016/j.hrthm.2020.11.008DOI Listing
March 2021

Temperature- and flow-controlled ablation/very-high-power short-duration ablation vs conventional power-controlled ablation: Comparison of focal and linear lesion characteristics.

Heart Rhythm 2021 Apr 27;18(4):553-561. Epub 2020 Oct 27.

Hôpital Cardiologique Haut Lévêque, Lyric Institute, Université de Bordeaux, Pessac, France.

Background: The QDOT MICRO catheter allows temperature- and flow-controlled (TFC) ablation and very-high-power short-duration (vHPSD) ablation.

Objective: The purpose of this study was to compare lesion characteristics between TFC/vHPSD ablation and standard power-controlled (PC) ablation.

Methods: Lesion characteristics in the right atrium, left atrium, and right ventricle (RV) of 6 sheep were compared between vHPSD (90 W/4 seconds, TC mode with 60°C target using QDOT) and standard radiofrequency settings (PC mode, 30 W/30 seconds with ThermoCool SmartTouch SF). Lesions in the left ventricle (LV) were compared, targeting 50 W for 60-second applications.

Results: Forty-six focal atrial lesions, 50 RV focal lesions, and 12 linear lesions were created by vHPSD ablation and PC ablation in each group of 6 animals. vHPSD ablation produced significantly larger focal atrial lesions in length (8.3 [6.4-9.7] mm vs 6.3 [5.2-7.4] mm; P = .0002), width (6.0 [5.3-6.9] mm vs 4.6 [3.8-5.4] mm; P <.0001), and surface area (39.4 [25.4-52.4] mm vs 23.6 [16.0-31.1] mm; P = .0001), with superior transmurality (89.1% vs 69.6%; P = .04) compared to PC ablation. vHPSD ablation produced significantly larger RV lesions in length (7.7 [7.0-8.7] mm vs 6.0 [4.8-6.9] mm; P <.0001), width (6.4 [5.4-7.5] mm vs 4.3 [3.6-5.2] mm; P <.0001), and area (39.4 [29.1-50.1] mm vs 19.9 [14.7-25.2] mm; P <.0001) but similar volume (P = .97) with shallower lesions (2.7 [2.2-3.4] mm vs 3.8 [3.0-4.4] mm; P <.0001). Atrial linear lesions were more homogeneous (P = .02), with fewer gaps in each line (P = .003) with vHPSD ablation. LV focal lesions (15 TFC mode; 21 PC mode) were similar in volume and depth, but lesion size showed less deviation (P <.05) in TFC than PC mode. Fewer steam pops were observed in TFC mode (0% vs 28.6%; P = .03). Hemorrhagic rings around the lesion core were generally smaller with TFC/vHPSD ablation (P <.05).

Conclusion: TFC/vHPSD ablation produces larger, shallower, more homogeneous, and less hemorrhagic lesions. vHPSD Ablation produces more transmural and contiguous linear lesions compared to PC ablation. LV lesions are more homogeneous with fewer steam pops in TFC ablation.
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http://dx.doi.org/10.1016/j.hrthm.2020.10.021DOI Listing
April 2021

One-point posterior ablation for complete isolation of the posterior left atrium.

HeartRhythm Case Rep 2020 Oct 14;6(10):738-740. Epub 2020 Jul 14.

Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan.

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http://dx.doi.org/10.1016/j.hrcr.2020.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573377PMC
October 2020

Double ventricular tachycardias associated with an anatomical isthmus identified by a computed tomography-derived channel.

J Cardiovasc Electrophysiol 2020 11 14;31(11):3061-3063. Epub 2020 Sep 14.

LIRYC Institute, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Bordeaux, France.

We describe a 47-year-old woman with ischemic ventricular tachycardia (VT) with repetitive implantable cardioverter-defibrillator shocks, requiring ablation. Preprocedural computed tomography (CT) demonstrated a single anatomical channel on the inferior-basal infarcted area between less than a 3-mm wall-thinning area and the mitral annulus, which suggested the circuit of two VTs observed. In addition, distribution of less than 2 mm and less than 3 mm wall-thinning area can explain the mechanism of the variation of the QRS morphology and S-QRS interval during entrainment. Ablation in this region resulted in no VT inducibility and the absence of any VTs for 2 years. CT wall thinning data may allow us to understand the mechanism and circuit of VT and aid VT ablation procedures.
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http://dx.doi.org/10.1111/jce.14735DOI Listing
November 2020

Novel mapping algorithm during catheter ablation for ventricular parasystole originating from left anterior fascicle.

J Arrhythm 2020 Aug 6;36(4):777-779. Epub 2020 Jul 6.

Department of Cardiology Tokyo Metropolitan Hiroo Hospital Tokyo Japan.

A 17-year-old woman presented with frequent palpitations and shortness of breath and was diagnosed with drug-refractory ventricular parasystole. We predicted that the parasystole originated from the left anterior fascicle (LAF). Detailed activation maps of both conduction systems, including the LAF, during sinus rhythm and ventricular parasystole were obtained using a parallel mapping system. We confirmed the earliest fascicular potential of the parasystole and performed catheter ablation with no complications. This novel mapping algorithm for simultaneous acquisition of multiple maps aided effective treatment of ventricular parasystole originating from the LAF.
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http://dx.doi.org/10.1002/joa3.12400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411214PMC
August 2020

Impedance, power, and current in radiofrequency ablation: Insights from technical, ex vivo, and clinical studies.

J Cardiovasc Electrophysiol 2020 11 13;31(11):2836-2845. Epub 2020 Aug 13.

IHU LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.

Background: Radiofrequency (RF) power is routinely considered during RF application. In contrast, impedance has been relatively poorly studied, despite also influencing RF lesion creation. The aim of this study was to examine the influence of electric impedance on RF lesion characteristics and on clinical RF ablation parameters.

Methods And Results: In the first part of the study, power and impedance were systematically varied and the resulting current was calculated using custom-made software. In the second part of the study, ablation lesions (n = 40) were analyzed in a porcine ex vivo model. RF applications were delivered in cardiac muscle preparations with systematically varied values of electric impedance using a contact force ablation catheter. In the third part of the study, n = 3378 clinical RF applications were analyzed, power, impedance, and current data were exported and correlated with clinical patient data. 20 ± 3 W/80 Ω, 30 ± 3 W/120 Ω, 40 ± 3 W/160 Ω, and 50 ± 3 W/200 Ω RF applications resulted in 498 ± 40, 499 ± 26, 500 ± 20, and 500 ± 16 mA RF current, which were not significantly different (p = .32). Ablation lesions were significantly different in depth and diameter when applied with the same power but different impedances (p < .01); lesion sizes decreased when increasing impedance. In clinical data, a large range of delivered current (e.g., 39-40 W: 530-754 mA) was measured, due to variations in impedance.

Conclusions: RF lesion creation is determined by current rather than by power. During clinical RF ablation procedures, impedance significantly influences current delivery and varies considerably between patients. Impedance and current are clinically relevant parameters that should be considered during RF ablation.
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http://dx.doi.org/10.1111/jce.14709DOI Listing
November 2020

Acute and mid-term outcome of ethanol infusion of vein of Marshall for the treatment of perimitral flutter.

Europace 2020 08;22(8):1252-1260

Bordeaux University Hospital (CHU), Cardiac Electrophysiology and Cardiac Stimulation Team, CHU Bordeaux, IHU Lyric, Université de Bordeaux, Avenue de Magellan, 33604 Bordeaux, France.

Aims: We hypothesized that an epicardial approach using ethanol infusion in the vein of Marshall (EIVOM) may improve the result of ablation for perimitral flutter (PMF).

Methods And Results: We studied 103 consecutive patients with PMF undergoing high-resolution mapping. The first 71 were treated with radiofrequency (RF) ablation alone (RF-group), and the next 32 underwent EIVOM followed by RF on the endocardial and epicardial mitral isthmus (EIVOM/RF-group). Contact force was not measured during ablation. Acute and 1-year outcomes were compared. Flutter termination rates were similar between the RF-group (63/71, 88.7%) and EIVOM/RF-group (31/32, 96.8%, P = 0.27). Atrial tachycardia (AT) terminated with EIVOM alone in 22/32 (68.6%) in the EIVOM/RF-group. Bidirectional block of mitral isthmus was always achieved in the EIVOM/RF-group, but significantly less frequently achieved in the RF-group (62/71, 87.3%; P = 0.05). Median RF duration for AT termination/conversion was shorter [0 (0-6) s in the EIVOM/RF-group than 312 (55-610) s in the RF-group, P < 0.0001], as well as for mitral isthmus block in the EIVOM/RF-group [246 (0-663) s] than in the RF-group [900 (525-1310) s, P < 0.0001]. Pericardial effusion was observed in 1/32 (3.2%) in EIVOM/RF-group and 5/71 (7.0%) in RF-group (P = 0.66); two in RF-group required drainage and one of them developed subsequent ischaemic stroke. One-year follow-up demonstrated fewer recurrences in the EIVOM/RF-group [6/32 (18.8%)] than in the RF-group [29/71 (40.8%), P = 0.04]. By multivariate analysis, only EIVOM was significantly associated with less AT recurrence (hazard ratio = 0.35, P = 0.018).

Conclusion: Ethanol infusion in the vein of Marshall may reduce RF duration required for PMF termination as well as for mitral isthmus block without severe complications, and the mid-term outcome may be improved by this approach.
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http://dx.doi.org/10.1093/europace/euaa137DOI Listing
August 2020

Patient characteristics, procedure details including catheter devices, and complications of catheter ablation for ventricular tachycardia: a nationwide observational study.

J Arrhythm 2020 Jun 5;36(3):464-470. Epub 2020 May 5.

Department of Clinical Epidemiology and Health Economics School of Public Health The University of Tokyo Tokyo Japan.

Background: Nationwide data are insufficient with respect to the characteristics of patients undergoing ventricular tachycardia (VT) ablation, complications of VT ablation, and procedure details including catheter devices used during VT ablation. The present study was performed to describe the patient characteristics, procedure details including catheter devices, and in-hospital complications of catheter ablation for VT using a national inpatient database.

Methods: We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify patients who underwent VT ablation from July 2010 to March 2017. We examined patients' age, gender, baseline diseases, comorbid conditions, admission status, catheter devices and drugs used, and in-hospital complications of VT ablation.

Results: We identified 10 641 patients (median age, 61 years) who underwent VT ablation. The most frequently observed background heart disease among patients with structural heart disease was ischemic cardiomyopathy. An irrigated ablation catheter was used in 73% of patients, a force-sensing ablation catheter was used in 22%, and intracardiac echocardiography was used in 25%. The frequency of using these procedures continuously increased over time. Overall, the prevalence of in-hospital complications was 3.5% (cardiac tamponade, 0.8%; stroke, 0.6%; critical bleeding, 1.9%; mechanical circulatory support, 0.9%; and in-hospital death, 0.8%).

Conclusions: The results of this study show the clinical features of VT ablation in a real-world clinical setting. The use of irrigated catheters, force-sensing catheters, and intracardiac echocardiography increased over time. The prevalence of in-hospital complications was 3.5%.
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http://dx.doi.org/10.1002/joa3.12356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279962PMC
June 2020

Quality of life improvements by durable pulmonary vein isolation in patients with atrial fibrillation.

J Cardiovasc Electrophysiol 2020 08 4;31(8):2013-2021. Epub 2020 Jun 4.

Department of Cardiovascular Disease, Tokyo Medical and Dental University, Tokyo, Japan.

Introduction: Successful pulmonary vein isolation (PVI) can improve the quality of life (QOL) of patients with atrial fibrillation (AF). However, the role of durable PVI for such QOL improvement is not known. The aim of this study was to clarify the effectiveness of durable PVI in improving the QOL of patients with AF.

Methods And Results: We assessed 119 patients who underwent PVI (age 66.4 ± 9.6 years, 104 paroxysmal AF). A scheduled electrophysiological study was performed 6 months after the first PVI session-regardless of recurrence of AF-to assess the durability of PVI and to identify and re-isolate reconnected pulmonary veins. QOL scores were evaluated by an AF-specific QOL questionnaire and checked at baseline, 6  months, and 1 year after the first session. In patients without AF recurrence (nonrecurrence group, n = 93), the scores at 6 months improved compared with those at baseline; conversely, the scores did not improve in patients with AF recurrence (n = 26). Nevertheless, the scores at 1 year improved compared with those at 6 months in both groups. Within the nonrecurrence group, the score difference between 6 months and baseline was higher in the durable PVI group (n = 58) than that in the nondurable PVI group (n = 35).

Conclusions: The QOL of AF patients improved by the resumption of sinus rhythm following PVI. Patients with durable PVI had increased QOL scores compared with those with nondurable PVI. The durability of PVI may achieve further improvements in the QOL of patients with AF.
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http://dx.doi.org/10.1111/jce.14592DOI Listing
August 2020

Atrial tachycardia circuits include low voltage area from index atrial fibrillation ablation relationship between RF ablation lesion and AT.

J Cardiovasc Electrophysiol 2020 07 1;31(7):1640-1648. Epub 2020 Jun 1.

LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux-Pessac, France.

Background: No study to date has used high-density mapping to investigate the relationship between prior radiofrequency (RF) lesions for persistent atrial fibrillation (PsAF) ablation and subsequent atrial tachycardias (ATs).

Methods: From 41 consecutive patients who underwent AT ablation at a second procedure using an ultrahigh-density mapping system, 22 patients (38 ATs) were included as they also had complete maps with a multipolar catheter and three-dimensional (3D) mapping system at the time of the first PsAF ablation procedure. We, therefore, compared voltage maps from the first AF ablation procedure to those from the subsequent AT ablation procedure, as well as the lesion sets used for AF ablation vs the activation patterns in AT during the second procedure.

Results: In the 38 ATs, 211 of 285 analyzed atrial areas displayed low voltage area (LVA) (74%). Eighteen percent (38/211) existed before the index ablation for AF while 82% (173/211) were newly identified as LVA during the second procedure. Ninety-nine percent (172/173) of the newly developed LVA colocalized with RF lesions delivered for PsAF. Of the 38 ATs, 89.5% (34/38) AT circuits were associated with newly developed LVA due to RF lesions whilst 10.5% (4/38) AT circuits were associated with pre-existing LVA observed at the index procedure. No AT circuit was completely independent from index RF lesions in this series.

Conclusions: Analysis of detailed 3D electroanatomical mapping demonstrates that most ATs after PsAF ablation are involving LVAs due to index RF lesions.
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http://dx.doi.org/10.1111/jce.14576DOI Listing
July 2020

In silico analysis of the relation between conventional and high-power short-duration RF ablation settings and resulting lesion metrics.

J Cardiovasc Electrophysiol 2020 06 21;31(6):1332-1339. Epub 2020 Apr 21.

Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Bordeaux, France.

Background: Use of lesion metric indices is a proposed strategy to support pulmonary vein isolation procedures and these indices show good correlations with lesion sizes. The aim of this in silico study is to provide a detailed analysis of radiofrequency (RF) settings, including high-power short-duration (HPSD) settings, and resulting lesion metric indices.

Methods And Results: A software program was designed which simulated virtual RF ablations. Lesion metric indices (Ablation index: AI, Lesion size index: LSI) were calculated based on underlying RF settings (contact force [CF], power, duration). In series of calculations, the applied settings were varied within defined ranges (CF: 1-80 g, power: 1-60 W, duration: 1-60 seconds). Overall, n = 388 000 virtual ablations were calculated. The resulting lesion metric indices were compared with each other and analyzed in relation to respective RF settings. Increasing contact force from 1 to 10 g resulted in a 4.4-fold LSI value, whilst increasing contact force from 10 to 20g resulted in a 1.5-fold value (P < .01). When RF power was increased by 10 W, lesion metric indices increased between 1.3- and 1.6-fold. A prolongation of RF duration by 10 seconds resulted in a 1.2-to-1.3-fold increase of lesion metric indices. HPSD RF applications of 50 W, 11 to 13 seconds, and 60 W, 8 to 10 seconds resulted in equivalent lesion metric indices when compared with 30 W, 30 seconds conventional ablations.

Conclusions: The findings support the clinical use of contact forces within a 10 to 20 g range. AI is more sensitive to RF duration, whereas LSI is more sensitive to contact force. HPSD RF settings can successfully be derived from lesion metric indices.
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http://dx.doi.org/10.1111/jce.14495DOI Listing
June 2020

Comparison of touch-up ablation rate and pulmonary vein isolation durability between hot balloon and cryoballoon.

J Cardiovasc Electrophysiol 2020 06 20;31(6):1298-1306. Epub 2020 Apr 20.

Tokyo Medical and Dental University, Tokyo, Japan.

Introduction: This study aimed to compare touch-up ablation (TUA) rates and pulmonary vein isolation (PVI) durability of hot balloon ablation (HBA) and cryoballoon ablation (CBA) in paroxysmal atrial fibrillation (PAF) patients.

Methods: In total, 137 PAF patients were enrolled in the study. Among them, 59 underwent two HBA procedures at 6-month intervals and 78 patients underwent two CBA sessions, both regardless of atrial fibrillation recurrence. Propensity score matching was performed to estimate similar patient characteristics between the HBA and CBA groups.

Results: Each group comprised of 46 matched patients for comparison. The TUA rate at the first session was higher for HBA (49 of 184 PVs) than for CBA (20 PVs) (P = .01), with the highest incidence at the left superior pulmonary vein (LSPV). The rates of PVI durability at the second session performed 7 months later were similar between HBA (168 of 184 PVs) and CBA (162 PVs) groups. The PVI durability rate at the TUA sites of the first session was higher for HBA than for CBA (41 of 49 PVs vs 10 PVs, respectively; P = .01). Fifty percent of the patients underwent HBA at 73°C for the LSPV. HBA performed at 73°C yielded a lower TUA rate than that at 70°C (16 of 23 PVs vs 7 of 23 PVs; P = .008).

Conclusions: While PVI durability was similar between HBA and CBA, the TUA rate was higher for HBA than for CBA, especially on the LSPV. For LSPV, HBA at a balloon temperature of 73°C may reduce the TUA rate.
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http://dx.doi.org/10.1111/jce.14485DOI Listing
June 2020

Bipolar radiofrequency catheter ablation between the left ventricular endocardium and great cardiac vein for refractory ventricular premature complexes originating from the left ventricular summit.

J Arrhythm 2020 Apr 14;36(2):363-366. Epub 2020 Feb 14.

Department of Cardiology Tokyo Metropolitan Hiroo Hospital Tokyo Japan.

Ablation for ventricular arrhythmias originating from the left ventricular (LV) summit is sometimes challenging. Bipolar radiofrequency catheter ablation (RFCA) is effective for refractory arrhythmias; little is known about bipolar RFCA from the coronary venous system and the appropriate settings. We experienced three cases of ventricular premature complexes (VPCs) originating from the LV summit successfully treated by bipolar RFCA between the LV endocardium (irrigated catheters as active electrodes) and coronary venous system (8-mm-tip catheters as return electrodes). These cases showed that bipolar RFCA was effective for the VPCs originating from the LV summit; 8-mm-tip catheters were useful as return electrodes.
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http://dx.doi.org/10.1002/joa3.12312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132175PMC
April 2020

Recurrent ischemic stroke in patients with atrial fibrillation ablation and prior stroke: A study based on etiological classification.

J Arrhythm 2020 Feb 3;36(1):95-104. Epub 2019 Dec 3.

Tokyo Medical and Dental University Tokyo Japan.

Background: Different subtypes of ischemic stroke may have different risk factors, clinical features, and prognoses. This study investigated the incidence and mode of stroke recurrence in patients with a history of stroke who underwent atrial fibrillation (AF) ablation.

Methods: Of 825 patients who underwent AF ablation from 2006 to 2016, 77 patients (9.3%, median age 69 years) with a prior ischemic stroke were identified. Patients were classified as those with prior cardioembolic (CE) stroke (n = 55) and those with prior non-CE stroke (n = 22). The incidence and pattern of stroke recurrence were investigated.

Results: The incidence of asymptomatic AF (54.5% vs 22.7%;  = .011) and left atrial volume (135.8 mL vs 109.3 mL;  = .024) was greater in the CE group than in the non-CE group. Anticoagulation treatment was discontinued at an average of 28.1 months following the initial ablation in 34 (44.2%) patients. None of the patients developed CE stroke during a median 4.1-year follow-up. In the non-CE group, 2 patients experienced recurrent non-CE stroke (lacunar infarction in 1 and atherosclerotic stroke in 1); however, AF was not observed at the onset of recurrent ischemic stroke.

Conclusions: In patients with a history of stroke who underwent catheter ablation for AF, the incidence of recurrent stroke was 0.54/100 patient-years. The previous stroke in these patients may not have been due to AF in some cases; therefore, a large-scale prospective study is warranted to identify the appro priate antithrombotic therapy for the prevention of potentially recurrent stroke.
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http://dx.doi.org/10.1002/joa3.12285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011801PMC
February 2020

Mechanism of Recurrence of Atrial Tachycardia: Comparison Between First Versus Redo Procedures in a High-Resolution Mapping System.

Circ Arrhythm Electrophysiol 2020 01 14;13(1):e007273. Epub 2020 Jan 14.

Cardiac Electrophysiology and Cardiac Stimulation Team, Bordeaux University Hospital (CHU), CHU Bordeaux, IHU Lyric, Université de Bordeaux, France (M.T., N.D., C.A.M., K.V., A.D., Y.N., T.K., G.C., F.B., A.L., R.M., A.F., N.T., G.M., M.W., W.E., C.A., L.-j.Z., J.D., T.P., F.S., H.C., M. Hocini, M. Haïssaguerre, P.J.).

Background: Atrial fibrillation ablation-related atrial tachycardia (AT) is complex and may demonstrate several forms: anatomic macroreentrant AT (AMAT), non-AMAT, and focal AT. We aimed to elucidate the recurrence rate and mechanisms of atrial fibrillation ablation-related AT recurrence.

Methods: Among 147 patients with ATs treated with the Rhythmia system, 68 (46.3%) had recurrence at mean 4.2 (2.9-11.6) months, and 44 patients received a redo procedure. AT circuits in the first procedure were compared with those in the redo procedure.

Results: Although mappable ATs were not observed in 7 patients, 68 ATs were observed in 37 patients during the first procedure: perimitral flutter (PMF) in 26 patients, roof-dependent macroreentrant AT (RMAT) in 18, peritricuspid flutter in 10, non-AMAT in 14, and focal AT in 3. During the redo AT ablation procedure, 54 ATs were observed in 41/44 patients: PMF in 24, RMAT in 14, peritricuspid flutter in 1, non-AMAT in 14, and focal AT in 1. Recurrence of PMF and RMAT was observed in 15 of 26 (57.7%) and 8 of 18 (44.4%) patients, respectively, while peritricuspid flutter did not recur. Neither the same focal AT nor the same non-AMAT were observed except in 1 case with septal scar-related biatrial AT. Epicardial structure-related ATs were involved in 18 of 24 (75.0%) patients in PMF, 4 of 14 (28.6%) in RMAT, and 4 of 14 (28.6%) in non-AMAT. Of 21 patients with a circuit including epicardial structures, 6 patients treated with ethanol infusion in the vein of Marshall did not show any AT recurrence, although 8 of 15 (53.3%) treated with radiofrequency showed AT recurrence (=0.04).

Conclusions: Although high-resolution mapping may lead to correct diagnosis and appropriate ablation in the first procedure, the recurrence rate is still high. The main mechanism of atrial fibrillation ablation-related AT is the recurrence of PMF and RMAT or non-AMAT different from the first procedure. Epicardial structures (eg, coronary sinus/vein of Marshall system) are often involved, and ethanol infusion in the vein of Marshall may be an additional treatment.
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http://dx.doi.org/10.1161/CIRCEP.119.007273DOI Listing
January 2020