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Diagnosis and Ablation of Atrial flutter: The Prototypical Reentrant Atrial Arrhythmia.

Authors:
Gregory K Feld

Heart Rhythm 2021 Apr 9. Epub 2021 Apr 9.

University of California, San Diego Health System. Electronic address:

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Spectrum of Arrhythmogenic Substrate Post Minimally Invasive Maze Surgery in Patients with Recurrent.

Pacing Clin Electrophysiol 2021 Apr 7. Epub 2021 Apr 7.

Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA.

Background: Advancements in minimally invasive surgical ablation (MISA) have focused on improving pulmonary vein isolation. Additional ablation targets have been developed (such as posterior wall isolation). The mid and long term effects of current techniques (including electrophysiologic findings and recurrent arrhythmia mechanisms) have not previously been reported. Read More

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Evaluation of Directed Graph-Mapping in Complex Atrial Tachycardias.

JACC Clin Electrophysiol 2021 Mar 25. Epub 2021 Mar 25.

Department of Physics and Astronomy, Ghent University, Ghent, Belgium.

Objectives: Directed graph mapping (DGM) is a novel operator-independent automatic tool that can be applied to the identification of the atrial tachycardia (AT) mechanism. In the present study, for the first time, DGM was applied in complex AT cases, and diagnostic accuracy was evaluated.

Background: Catheter ablation of ATs still represents a challenge, as the identification of the correct mechanism can be difficult. Read More

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Utility of coherent and ripple mapping for post-mitral valve plasty biatrial macro-re-entrant tachycardia: a case report.

Eur Heart J Case Rep 2021 Feb 12;5(2):ytaa547. Epub 2021 Jan 12.

Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ward, Tokyo 113-8510, Japan.

Background : Biatrial tachycardia (BiAT) is a rare form of atrial macro-re-entrant tachycardia. Precise identification of interatrial connections and circuits of the BiAT is difficult. And incomplete understanding of the re-entrant circuit may lead to unnecessary ablation, thus increasing the risk of complications. Read More

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February 2021

The Left Atrial Appendage Ostium: Hotspots for Localized Re-Entry.

JACC Clin Electrophysiol 2021 Mar 25;7(3):333-342. Epub 2020 Nov 25.

Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA.

Objectives: The goal of this study was to characterize the location and electrophysiological properties of left atrial appendage (LAA) atrial tachycardia (AT).

Background: The LAA has been reported to be a source of AT and atrial fibrillation (AF) triggers.

Methods: This study retrospectively reviewed ATs mapped to the LAA. Read More

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Characterization of cardiac electrogram signals in atrial arrhythmias.

Minerva Cardiol Angiol 2021 Feb;69(1):70-80

Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy.

Despite significant advancements in 3D cardiac mapping systems utilized in daily electrophysiology practices, the characterization of atrial substrate remains crucial for the comprehension of supraventricular arrhythmias. During mapping, intracardiac electrograms (EGM) provide specific information that the cardiac electrophysiologist is required to rapidly interpret during the course of a procedure in order to perform an effective ablation. In this review, EGM characteristics collected during sinus rhythm (SR) in patients with paroxysmal atrial fibrillation (pAF) are analyzed, focusing on amplitude, duration and fractionation. Read More

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February 2021

Ligament of Marshall ablation for persistent atrial fibrillation.

Pacing Clin Electrophysiol 2021 Mar 9. Epub 2021 Mar 9.

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. Read More

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Ablation Index-guided high-power (50 W) short-duration for left atrial anterior and roofline ablation: Feasibility, procedural data, and lesion analysis (AI High-Power Linear Ablation).

J Cardiovasc Electrophysiol 2021 Apr 8;32(4):984-993. Epub 2021 Mar 8.

Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany.

Objectives: To evaluate the feasibility, procedural data, and lesion characteristics of the anterior line (AL) and roofline (RL) ablation by using ablation index (AI)-guided high power (50 W) among patients with recurrent atrial fibrillation (AF) or atrial tachycardia (AT) after pulmonary vein isolation (PVI).

Methods: Data from 35 consecutive patients with macro-reentrant left atrial tachycardia or substrate at the left atrium anterior wall or roof after previous PVI were collected. Ablation power was set to 50 W, targeting AI 500 for AL and 400 for RL. Read More

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High-density Grid Mapping of Micro- and Macro-reentrant Left Atrial Arrhythmias.

J Innov Card Rhythm Manag 2021 Jan 15;12(Suppl 1):28-30. Epub 2021 Jan 15.

Electrophysiology Section, Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.

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January 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. Read More

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February 2021

Delayed management of atrial lead dislodgment after pacemaker implantation: a case report.

J Med Case Rep 2021 Jan 14;15(1). Epub 2021 Jan 14.

Department of Cardiology, Capital Medical University affiliated Beijing Shijitan Hospital, No 10 Tieyi Road, Haidian, Yangfangdian, Beijing, China.

Background: Pacemaker lead dislodgement may cause malfunction in the pacing system, which may lead to severe adverse events. For patients with sick sinus syndrome but normal atrioventricular conduction, atrial lead dislocation may cause excessive unnecessary ventricular pacing, resulting in nonphysiological pacing leading to heart failure. The longer the unwanted ventricular pacing continues, the greater the chances that irreversible heart failure may occur. Read More

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January 2021

Electrophysiological characteristics of epicardial to endocardial breakthrough in intractable cavotricuspid isthmus-dependent atrial flutter.

Pacing Clin Electrophysiol 2021 Mar 31;44(3):462-471. Epub 2021 Jan 31.

Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.

Background: Epicardial to endocardial breakthrough (EEB) exists widely in atrial arrhythmia and is a cause for intractable cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL). This study aimed to investigate the electrophysiological features of EEB in EEB-related CTI dependent AFL.

Methods: Six patients with EEB-related CTI-dependent AFL were identified among 142 consecutive patients who underwent CTI-dependent AFL catheter ablation with an ultra-high-density, high-resolution mapping system in three institutions. Read More

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Sight Is a Faculty, Seeing Is an Art: Rethinking Left Atrial Macro-Re-Entry in 3 Dimensions.

JACC Clin Electrophysiol 2020 12;6(14):1824-1826

Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

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December 2020

Indirect and Direct Evidence for 3-D Activation During Left Atrial Flutter: Anatomy of Epicardial Bridging.

JACC Clin Electrophysiol 2020 12;6(14):1812-1823

University of Chicago Pritzker School of Medicine, Center for Arrhythmia Care at the University of Chicago Medicine, Chicago, Illinois, USA. Electronic address:

Objectives: This study sought to describe arrhythmia characteristics using ultra-high density (UHD) mapping of macro-re-entrant left atrial flutter (LAFL) which propagate via epicardial bridging (EB), and highlight regional anatomy that poses challenges to ablation.

Background: Three-dimensional propagation via EB may contribute to the maintenance and complexity of LAFL.

Methods: UHD activation maps of macro-re-entrant LAFL created with a mini-electrode basket catheter were analyzed between June 2015 and March 2020. Read More

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December 2020

Complexity and Disorder of 1/ Noises.

Entropy (Basel) 2020 Oct 4;22(10). Epub 2020 Oct 4.

Department of Photonics, National Chiao Tung University, Hsinchu 30010, Taiwan.

The complexity and the disorder of a 1/fα noise time series are quantified by entropy of entropy (EoE) and average entropy (AE), respectively. The resulting EoE vs. AE plot of a series of 1/fα noises of various values of α exhibits a distinct inverted U curve. Read More

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October 2020

Macro-reentrant Single-loop Biatrial Flutter Appearing as Typical Atrial Flutter: Case Study and Review.

J Innov Card Rhythm Manag 2020 Nov 15;11(11):4306-4312. Epub 2020 Nov 15.

Department of Cardiothoracic Surgery, Hoffman Heart and Vascular Institute, St. Francis Hospital and Medical Center, University of Connecticut School of Medicine, Hartford, CT, USA.

Biatrial flutter is a rare form of macro-reentrant atrial tachycardia that involves both the right and left atria. Single-loop biatrial flutter is typically associated with scarring of the septum from prior ablation or surgery and is generally made up of two interatrial connections-that is, the coronary sinus and Bachmann's bundle. Entrainment and high-density mapping allow for rapid diagnosis and development of a treatment strategy. Read More

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November 2020

Catheter ablation of atrial arrhythmias following lung transplant: Electrophysiological findings and outcomes.

J Cardiovasc Electrophysiol 2021 Jan 25;32(1):49-57. Epub 2020 Nov 25.

Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Introduction: Data on the mechanisms of atrial arrhythmias (AAs) and outcomes of catheter ablation (CA) in lung transplantation (LT) patients are insufficient. We evaluated the electrophysiologic features and outcomes of CA of AAs in LT patients. METHODS AND RESULTS: We conducted a retrospective study of all the LT patients who underwent CA for AAs at our institution between 2004 and 2019. Read More

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January 2021

Ablation of atrial tachycardia in the setting of prior mitral valve surgery.

Minerva Cardiol Angiol 2021 Feb 4;69(1):94-101. Epub 2020 Nov 4.

Department of Medicine and Surgery, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi University Hospital, Varese, Italy 2 Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate, Varese, Italy -

Background: Data regarding catheter ablation of post-surgical atrial tachycardia occurring after mitral valve surgery are scarce. Through a search of the literature, this study aimed to assess the feasibility of catheter ablation and the characteristics of atrial arrhythmias ablated in these patients.

Methods: Studies assessing the main procedure parameters and the electrophysiologic findings of the investigated atrial tachycardia were selected. Read More

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February 2021

Successful Catheter Ablation of Two Macro-reentrant Atrial Tachycardias in a Patient with Congenitally Corrected Transposition of the Great Arteries: A Case Report.

J Innov Card Rhythm Manag 2020 Oct 15;11(10):4273-4280. Epub 2020 Oct 15.

Division of Adult Cardiology, Medical College of Georgia, Augusta, GA, USA.

Adults with congenital heart disease represent a complex and growing patient population. By virtue of their variant anatomy and the complex surgical repair often required in infancy, these patients are at risk of developing unique atrial and ventricular arrhythmias throughout their lifetimes. Electrophysiologists involved in the care of these patients should have a detailed understanding of their underlying anatomy and any prior surgical procedures to guide procedural planning and should have knowledge of the range of possible arrhythmia mechanisms that may differ from patients without structural heart disease. Read More

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October 2020

Transcatheter mitral valve implantation using a novel system: preclinical results.

J Geriatr Cardiol 2020 Sep;17(9):566-573

Department of Cardiovascular Surgery, the First Affiliated Hospital of Air Force Military Medical University, Xi'an, China.

Background: This preclinical study in sheep sought to demonstrate the initial safety and feasibility of a novel transcatheter mitral valve system (Mi-thos valve) composed of a self-expanding frame and a bovine pericardial tissue bioprosthesis.

Methods: The valve was implanted in 26 sheep using a transapical approach for short- and long-term evaluation. The technical feasibility, safety, durability, and valve function were evaluated during and 6 months after the procedure using intracardiac and transthoracic echocardiography, multisliced computed tomography, histological analysis, and electron microscopy. Read More

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September 2020

Subclinical macro and microvascular disease is differently associated with depressive symptoms in men and women: Findings from the SABRE population-based study.

Atherosclerosis 2020 11 13;312:35-42. Epub 2020 Sep 13.

MRC Unit for Lifelong Health and Ageing, Institute of Cardiovascular Science, University College London, London, United Kingdom.

Background And Aims: Mechanisms underlying the association between cardiovascular disease (CVD) and depression are unknown, and sex differences understudied. We investigated associations between a comprehensive set of measures of macro and microvascular disease and depressive symptoms in older men and women.

Methods: We performed cross-sectional analyses of the SABRE (Southall And Brent REvisited) population-based study. Read More

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November 2020

The ligament of Marshall and arrhythmias: A review.

Pacing Clin Electrophysiol 2020 Sep 11. Epub 2020 Sep 11.

Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China.

The ligament of Marshall (LOM) is a remnant of the embryonic sinus venosus and left cardinal vein, and contains fat and fibrous tissues, blood vessels, muscle bundles, nerve fibers, and ganglia. The complexity of LOM's structure makes it as a source of triggers and drivers as well as substrates of re-entry for atrial arrhythmias, especially for atrial fibrillation (AF). LOM also serves as a portion of left atrial macro-re-entrant circuit, especially peri-mitral isthmus re-entrant circuit. Read More

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September 2020

Dynamic voltage threshold adjusted substrate modification technique for complex atypical atrial flutters with varying circuits.

Pacing Clin Electrophysiol 2020 11 26;43(11):1273-1280. Epub 2020 Sep 26.

Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington.

Background: Atypical atrial flutter (AFL) is common in patients with postsurgical atrial scar, with macro- or microscopic channels in the scar acting as substrate for reentry. Heterogeneous atrial scarring can cause varying flutter circuits, which makes mapping and ablation challenging, and recurrences common.

Aim: We hypothesize that dynamically adjusting voltage thresholds can identify heterogeneous atrial scarring, which can then be effectively homogenized to eliminate atypical AFLs. Read More

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November 2020

High-density mapping of multiple atypical atrial flutter. First HD GRID mapping experience among The Commonwealth of Independent States.

J Arrhythm 2020 Aug 16;36(4):771-773. Epub 2020 Jun 16.

Cardiology Department JSC "Astana Medical University Nur-Sultan Kazakhstan.

Mapping of multiple atrial tachycardias after previous cryoballoon pulmonary vein isolations and multiple radiofrequency ablations can be challenging even for experienced specialists. HD Grid high-density mapping catheter is one of the catheters, which helps not only to precisely identify the mechanisms of macro-reentry tachycardia but also to avoid unnecessary radiofrequency applications. Accordingly, we present two cases of complex atrial arrhythmia with the use of HD Grid, which showed clear visualization of mechanisms and target ablations with the termination of tachycardia. Read More

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Intracerebral haemorrhage, microbleeds and antithrombotic drugs.

Rev Neurol (Paris) 2021 Jan-Feb;177(1-2):11-22. Epub 2020 Jul 31.

University of Lille, Inserm, CHU of Lille, U1172-LilNCog-Lille Neuroscience & Cognition, 59000 Lille, France.

Antithrombotic therapy is a cornerstone for secondary prevention of ischaemic events, cerebral and extra-cerebral. A number of clinical questions remain unanswered concerning the impact of antithrombotic drugs on the risk of first-ever and recurrent macro or micro cerebral haemorrhages, raising the clinical dilemma on the risk/benefit balance of giving antiplatelets and anticoagulants in patients with potential high risk of brain bleeds. High field magnetic resonance imaging (MRI) blood-weighted sequences, including susceptibility weighted imaging (SWI), have expanded the spectrum of these clinical questions, because of their increasing sensitivity in detecting radiological markers of small vessel disease. Read More

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Characterization of Complex Atrial Tachycardia in Patients With Previous Atrial Interventions Using High-Resolution Mapping.

JACC Clin Electrophysiol 2020 07 27;6(7):815-826. Epub 2020 May 27.

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

Objectives: This study systematically evaluated mechanisms of atrial tachycardia (AT) by using ultra-high-resolution mapping in a large cohort of patients.

Background: An incomplete understanding of the mechanism of AT is a major determinant of ablation failure.

Methods: Consecutive patients with ≥1 AT (excluding cavotricuspid isthmus-dependent flutter) were included. Read More

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Prevalence of intra-atrial reentrant tachycardia following mitral valve surgery: Relationship to surgical approach.

J Card Surg 2020 Aug 11;35(8):1871-1876. Epub 2020 Jul 11.

Providence Medical Research Center, Providence Health Care, Spokane, Washington.

Background And Aim: Mitral valve (MV) surgeries create electrophysiological substrates that give rise to postoperative arrhythmias. MV surgical procedures have been associated with macro- and microreentrant arrhythmogenic circuits, as well as circuits involving the atrial roof. It is not well understood why such arrhythmias develop; therefore, the aim of this study was to describe clinical and procedure characteristics associated with atrial arrhythmias in patients with prior MV surgery. Read More

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Electrophysiological Characteristics and Outcomes of Radiofrequency Catheter Ablation of Atrial Flutter in Children with or Without Congenital Heart Disease.

Pediatr Cardiol 2020 Oct 8;41(7):1509-1514. Epub 2020 Jul 8.

Department of Pediatric Cardiology, Heart Center, the First Hospital of Tsinghua University, Beijing Huaxin Hospital, No.6 Jiuxianqiao 1st Road, Chaoyang District, Beijing, 100016, China.

There are scarce studies on radiofrequency catheter ablation (RFCA) of atrial flutter (AFL) in the pediatric population. This study therefore aimed to investigate the clinical features and RFCA of AFL in children with or without congenital heart disease. Data from 72 consecutive children (44 males; mean age, 6. Read More

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October 2020

Epicardial bridge via the coronary sinus musculatures revealed by ultra-high-definition mapping.

J Electrocardiol 2020 Jul - Aug;61:106-111. Epub 2020 Apr 24.

Department of Cardiac Electrophysiology, University of Iowa, IA, USA.

Mapping and ablation of perimitral flutter, a macro-reentrant tachycardia, can be sometimes challenging. We describe a case of perimitral atrial flutter following the pulmonary vein isolation in which mitral isthmus ablation failed to terminate the arrhythmia due to epicardial-endocardial breakthrough via the muscle fibers of coronary sinus. Ultra-high-definition mapping system was utilized to locate the epicardial bridge, and spot ablation of the lesion subsequently terminated the arrhythmia. Read More

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