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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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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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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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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

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

Significance of post-pacing intervals shorter than tachycardia cycle length for successful catheter ablation of atypical flutter.

Europace 2021 Apr;23(4):624-633

Cardiology Division, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.

Aims: During entrainment mapping of macro-reentrant tachycardias, the time difference (dPPI) between post-pacing interval (PPI) and tachycardia cycle length (TCL) is thought to be a function of the distance of the pacing site to the re-entry circuit and dPPI < 30 ms is considered within the re-entry circuit. This study assessed the importance of PPI < TCL as a successful target for atypical flutter ablation.

Methods And Results: A total of 177 ablation procedures were investigated. Read More

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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

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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Identification of critical isthmus using coherent mapping in patients with scar-related atrial tachycardia.

J Cardiovasc Electrophysiol 2020 06 6;31(6):1436-1447. Epub 2020 Apr 6.

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

Introduction: Accurate identification of slow conducting regions in patients with scar-related atrial tachycardia (AT) is difficult using conventional electrogram annotation for cardiac electroanatomic mapping (EAM). Estimating delays between neighboring mapping sites is a potential option for activation map computation. We describe our initial experience with CARTO 3 Coherent Mapping (Biosense Webster Inc,) in the ablation of complex ATs. Read More

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Transseptal puncture without fluoroscopy using a radiofrequency needle: A case series.

Cardiol J 2020 Feb 10. Epub 2020 Feb 10.

Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany., Bad Oeynhausen, Germany.

Background: The non-fluoroscopy approach with the use of a three-dimensional (3D) navigation system is increasingly recognized as a future technology in the treatment of arrhythmias. However, there are a limited number of articles published concerning transseptal puncture without the use of fluoroscopy.

Methods: Presented in this paper is the first series of patients (n = 10) that have undergone transseptal puncture without the use of fluoroscopy under transesophageal echocardiography control using a radiofrequency transseptal needle and a 3D navigation system. Read More

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February 2020

Atrial Tachycardia With Atrial Activation Duration Exceeding the Tachycardia Cycle Length: Mechanisms and Prevalence.

JACC Clin Electrophysiol 2019 08 31;5(8):907-916. Epub 2019 Jul 31.

Department of Cardiology, University Hospital Haut-Lévèque, Pessac, France; LIRYC Institute/INSERM 1045, Bordeaux University Hospital, Bordeaux, France.

Objectives: This study sought to identify atrial tachycardia (AT) demonstrating atrial activation duration (AAD) lasting longer than the length of the tachycardia cycle (TCL); to assess AT prevalence; and to evaluate the mechanisms and characteristics associated with these AT episodes by using the Rhythmia system (Boston Scientific, Marlborough, Massachusetts).

Background: Ultra-high-density mapping allows very accurate characterization of mechanisms involved in AT. Some complex patterns may involve AAD which is longer than the tachycardia cycle length (TCL) which makes maps difficult to interpret. Read More

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Lateral tunnel Fontan atrial tachycardia ablation trans-baffle access is not mandatory as the initial strategy.

J Interv Card Electrophysiol 2020 Sep 9;58(3):299-306. Epub 2019 Aug 9.

Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.

Background: Mapping and ablation of atrial tachycardia (AT) is commonly performed in lateral tunnel Fontan (LTF) patients, yet there is little information on the need of baffle puncture to access the pulmonary venous atrium (PVA). This study aimed to evaluate the most common chamber location of critical sites for majority of AT in LTF patients.

Methods: Consecutive LTF patients underwent catheter-based high-density mapping and ablation of AT from Nov. Read More

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September 2020

High-Density Mapping and Ablation of Primary Nonfocal Left Atrial Tachycardia: Characterizing a Distinct Arrhythmogenic Substrate.

JACC Clin Electrophysiol 2019 04 27;5(4):417-426. Epub 2019 Mar 27.

Department of Cardiology-Electrophysiology, University Hospital Hamburg, University Heart Center, and the DZHK Hamburg, Hamburg, Germany.

Objectives: This study sought to characterize primary left atrial tachycardia (LAT) mechanisms, electrical properties and substrate using high-density mapping.

Background: Nonfocal LAT can be found in patients without prior substrate modifying interventions.

Methods: Of 223 catheter ablation procedures for LAT 15 patients (60% male, age 74 ± 6 years) had nonfocal AT and no history of LA ablation or cardiac surgery. Read More

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Characterization of the Mechanism and Substrate of Atrial Tachycardia Using Ultra-High-Density Mapping in Adults With Congenital Heart Disease: Impact on Clinical Outcomes.

J Am Heart Assoc 2019 02;8(4):e010535

1 Royal Brompton and Harefield NHS Foundation Trust London United Kingdom.

Background Atrial tachycardia ( AT ) is common in patients with adult congenital heart disease and is challenging to map and ablate. We used ultra-high-density mapping to characterize the AT mechanism and investigate whether substrate characteristics are related to ablation outcomes. Methods and Results A total of 50 AT s were mapped with ultra-high-density mapping in 23 procedures. Read More

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February 2019

Noninvasive mapping before surgical ablation for persistent, long-standing atrial fibrillation.

J Thorac Cardiovasc Surg 2019 01 25;157(1):248-256. Epub 2018 Sep 25.

Washington Adventist Hospital, Takoma Park, Md; West Virginia University, Morgantown, WVa.

Objective: The study objective was to study the electrophysiologic mechanism of atrial fibrillation using a noninvasive, beat-by-beat, 3-dimensional mapping technique in patients with persistent and long-standing persistent atrial fibrillation undergoing concomitant surgical ablation.

Methods: In this pilot trial, 10 patients (6 male; mean age, 70 ± 10 years) with persistent atrial fibrillation were mapped preoperatively with a noninvasive surface system (ECVUE, CardioInsight, Medtronic Inc, Minneapolis, Minn). Eight patients were candidates for mitral valve surgery, 1 patient was a candidate for aortic valve and ascending aortic replacement, and 1 patient was a candidate for coronary bypass surgery. Read More

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January 2019

Evaluation of Electrophysiological Mechanisms of Post-Surgical Atrial Tachycardias Using an Automated Ultra-High-Density Mapping System.

JACC Clin Electrophysiol 2018 11 29;4(11):1460-1470. Epub 2018 Aug 29.

Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China; Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China. Electronic address:

Objectives: This study aimed to evaluate the electrophysiological mechanisms of post-surgical atrial tachycardias (ATs) during mapping with an automated high-resolution mapping system (Rhythmia, Boston Scientific, Marlborough, Massachusetts).

Background: Mapping and ablation of post-operative ATs following previous open-heart surgery is often challenging because the potential mechanisms remain incompletely understood.

Methods: Fifty-one consecutive patients underwent mapping and ablation of post-surgical ATs. Read More

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November 2018

Catheter Ablation of Ventricular Arrhythmia for Ebstein's Anomaly in Unoperated and Post-Surgical Patients.

JACC Clin Electrophysiol 2018 10 27;4(10):1300-1307. Epub 2018 Jun 27.

Arrhythmia Center, Department of Cardiology, University of California, Los Angeles, Los Angeles, California.

Objectives: The purpose of this study was to determine the ventricular arrhythmia (VA) substrates in patients with unoperated and post-surgical Ebstein's Anomaly (EA).

Background: EA is associated with variable atrialization of the right ventricle and a propensity for VA and sudden death. There are scant data on catheter ablation for VA in this population. Read More

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October 2018

Atrial Tachycardias After Surgical Atrial Fibrillation Ablation: Clinical Characteristics, Electrophysiological Mechanisms, and Ablation Outcomes From a Large, Multicenter Study.

JACC Clin Electrophysiol 2017 08 31;3(8):865-874. Epub 2017 May 31.

University of Kansas Medical Center, Kansas City, Kansas. Electronic address:

Objectives: The clinical characteristics, electrophysiological mechanisms, and ablation outcomes of post-surgical atrial fibrillation ablation (SAFA) atrial tachycardias (ATs) have not been studied in a large, multicenter cohort.

Background: ATs are often seen following SAFA.

Methods: Analysis was performed on 137 patients (age, 62 ± 10 years; 74% male) who underwent catheter ablation for symptomatic post-SAFA AT from 2004 to 2013 at 3 high-volume institutions in the United States. Read More

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Typical Flutter Rewritten: From Textbooks to Ultra-High-Definition Mapping.

JACC Clin Electrophysiol 2017 09 31;3(9):987-990. Epub 2017 May 31.

Centre Hospitalier Princesse Grace, Monaco.

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September 2017

New Insights Into an Old Arrhythmia: High-Resolution Mapping Demonstrates Conduction and Substrate Variability in Right Atrial Macro-Re-Entrant Tachycardia.

JACC Clin Electrophysiol 2017 09 31;3(9):971-986. Epub 2017 May 31.

Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Australia. Electronic address:

Objectives: Using high-resolution 3-dimensional (3D) mapping, the aim of this study was to further characterize right atrial macro-re-entrant tachycardias and answer unresolved questions in the understanding of this arrhythmia.

Background: Despite advances in understanding of the mechanisms of right atrial macro-re-entrant tachycardias, many questions lack definitive answers. The advent of high-resolution 3D mapping provides an opportunity to gain further insights into the nature of these common circuits. Read More

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September 2017

Useful Electrocardiographic Features to Help Identify the Mechanism of Atrial Tachycardia Occurring After Persistent Atrial Fibrillation Ablation.

JACC Clin Electrophysiol 2018 01 27;4(1):33-45. Epub 2017 Sep 27.

Hôpital Cardiologique du Haut-Lévêque and Université de Bordeaux, IHU LIRYC ANR-10-IAHU-04, Bordeaux-Pessac, France.

Objectives: The purpose of this study was to describe and identify useful electrocardiographic characteristics to help identify the mechanism of atrial tachycardia (AT) occurring after persistent atrial fibrillation (PsAF) ablation.

Background: Electrocardiographic analysis to help identify the mechanism of AT after PsAF ablation is much limited by the fact that remodeling and ablation alter the normal activation pattern.

Methods: All consecutive patients who underwent mapping and ablation of AT after PsAF ablation were included. Read More

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January 2018

Contrast between Spain and the Netherlands in the hidden obstacles to re-entry into the labour market due to a criminal record.

Eur J Criminol 2017 Sep 15;14(5):505-521. Epub 2016 Nov 15.

Universitat Pompeu Fabra, Spain.

This article aims at analysing the differences between European countries in the obstacles ex-offenders face due to having a criminal record. First, a comparative analytical framework is introduced that takes into account all the different elements that can lead to exclusion from the labour market by the dissemination of criminal record information. This model brings together social norms (macro level), social actors (meso level) and individual choices (micro level) in the same framework. Read More

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September 2017

Computational assessment of the functional role of sinoatrial node exit pathways in the human heart.

PLoS One 2017 5;12(9):e0183727. Epub 2017 Sep 5.

Institute of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom.

Aim: The human right atrium and sinoatrial node (SAN) anatomy is complex. Optical mapping experiments suggest that the SAN is functionally insulated from atrial tissue except at discrete SAN-atrial electrical junctions called SAN exit pathways, SEPs. Additionally, histological imaging suggests the presence of a secondary pacemaker close to the SAN. Read More

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October 2017

Atrial Flutter, Typical and Atypical: A Review.

Arrhythm Electrophysiol Rev 2017 Jun;6(2):55-62

Getafe University Hospital, European University of Madrid, Madrid, Spain.

Clinical electrophysiology has made the traditional classification of rapid atrial rhythms into flutter and tachycardia of little clinical use. Electrophysiological studies have defined multiple mechanisms of tachycardia, both re-entrant and focal, with varying ECG morphologies and rates, authenticated by the results of catheter ablation of the focal triggers or critical isthmuses of re-entry circuits. In patients without a history of heart disease, cardiac surgery or catheter ablation, typical flutter ECG remains predictive of a right atrial re-entry circuit dependent on the inferior vena cava-tricuspid isthmus that can be very effectively treated by ablation, although late incidence of atrial fibrillation remains a problem. Read More

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Dual loop reentrant tachycardia with a combination of a localized reentry and a macro-reentry.

J Cardiol Cases 2017 Jun 14;15(6):197-200. Epub 2017 Apr 14.

Hôpital Cardiologique du Haut Lévêque-(CHU) de Bordeaux, Bordeaux, Pessac, France.

A 78-year-old woman presented 2 years after mitral valve replacement for rheumatic mitral stenosis with cardioversion-resistant atrial tachycardia (AT). Dual-loop AT was identified by activation mapping with the Rhythmia™ system (Boston Scientific, Marlborough, MA, USA) and confirmed by entrainment-mapping; one circuit with localized re-entry turned around the scar on the posterior left atrium and the other circuit, which was macro re-entrant, turned around the left superior pulmonary vein (LSPV) using the PV-carina, the ridge beween the left atrial appendage and the LSPV, and the roof. The two wavefronts fused on the posterior wall close to the LSPV. Read More

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Local activation time sampling density for atrial tachycardia contact mapping: how much is enough?

Europace 2018 02;20(2):e11-e20

Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London.

Aims: Local activation time (LAT) mapping forms the cornerstone of atrial tachycardia diagnosis. Although anatomic and positional accuracy of electroanatomic mapping (EAM) systems have been validated, the effect of electrode sampling density on LAT map reconstruction is not known. Here, we study the effect of chamber geometry and activation complexity on optimal LAT sampling density using a combined in silico and in vivo approach. Read More

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February 2018

Bundle Branch Re-Entrant Ventricular Tachycardia: Novel Genetic Mechanisms in a Life-Threatening Arrhythmia.

JACC Clin Electrophysiol 2017 03 21;3(3):276-288. Epub 2016 Dec 21.

Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California.

Objectives: This study sought to investigate for an underlying genetic etiology in cases of apparent idiopathic bundle branch re-entrant ventricular tachycardia (BBRVT).

Background: BBRVT is a life-threatening arrhythmia occurring secondary to macro-re-entry within the His-Purkinje system. Although classically associated with dilated cardiomyopathy, BBRVT may also occur in the setting of isolated, unexplained conduction system disease. Read More

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Investigations into Retinal Pathology in the Early Stages of a Mouse Model of Alzheimer's Disease.

J Alzheimers Dis 2017 ;56(2):655-675

Ophthalmic Research Laboratories, Hanson Institute Centre for Neurological Diseases, Adelaide, SA, Australia.

There is increasing recognition that visual performance is impaired in early stages of Alzheimer's disease (AD); however, no consensus exists as to the mechanisms underlying this visual dysfunction, in particular regarding the timing, nature, and extent of retinal versus cortical pathology. If retinal pathology presents sufficiently early, it offers great potential as a source of novel biomarkers for disease diagnosis. The current project utilized an array of immunochemical and molecular tools to perform a characterization of retinal pathology in the early stages of disease progression using a well-validated mouse model of AD (APPSWE/PS1ΔE9). Read More

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February 2018

Early Results of the Modified Right Atrial Lesion Set for the Cox-CryoMaze Procedure.

Innovations (Phila) 2016 Sep/Oct;11(5):342-348

From the Aegis Cardiovascular Research Foundation, Leesburg, FL USA.

Objective: The standard right atrial lesion (RAL) set, as originally outlined in the Cox-Maze III procedure, can be technically challenging when using a cryoprobe to create the lesions. We report our initial experience with an alternative set of RALs for the surgical treatment of atrial fibrillation (AF).

Methods: Between September 2011 and January 2015, a total of 112 patients underwent a CryoMaze procedure with biatrial lesions using argon-based cryoablation (cryoprobe temperature, -160°C). Read More

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