51 research outputs found
Persistent Atrial Fibrillation Phenotypes and Ablation Outcomes: Persistent From Outset vs Progression From Paroxysmal AF
No full textAvailable online 27 September 2024BACKGROUND: Many patients with persistent atrial fibrillation (PsAF) have progressed from an initial paroxysmal phenotype; however, there are patients in whom atrial fibrillation (AF) is persistent at diagnosis. Relatively little is known about this subgroup, but prior observational studies have suggested these patients have worse outcomes with ablation. OBJECTIVES: This study sought to: 1) assess demographic and electrophysiologic characteristics of patients with PsAF at first diagnosis compared with those with who have progressed from paroxysmal atrial fibrillation (PAF); and 2) assess the impact of pattern of AF at diagnosis on recurrence post ablation. METHODS: CAPLA (Catheter Ablation for persistent atrial fibrillation: A Multicentre randomised trial of Pulmonary vein isolation [PVI] vs PVI with posterior Left Atrial wall isolation [PWI]) was a multicenter trial that randomized patients with PsAF to PVI plus PWI or PVI alone. Follow-up was 12 months. Outcomes were assessed after a 3-month blanking period. RESULTS: A total of 334 patients were included (median age 65.6 years, 23.1% female), 194 (58.1%) had PsAF at first AF diagnosis and 140 (41.9%) had PAF. Patients with PsAF at diagnosis were younger (age 64.0 vs 67.7 years, P = 0.005), had higher rates of heart failure (P < 0.001), and lower left ventricular ejection fraction (54.5% IQR: 40-60 vs 60% IQR: 50-61, P = 0.007). AF recurrence occurred in 85 (43.8%) with PsAF at diagnosis and 70 (50%) with PAF at diagnosis. PsAF at diagnosis was not associated with risk of recurrence on univariable (HR: 0.802; 95% CI: 0.585-1.101; P = 0.173) or multivariable analysis (HR: 0.922; 95% CI: 0.647-1.312; P = 0.650). Median AF burden was 0% in both groups (P = 0.125). There was no difference in left atrial size (P = 0.337) or bipolar voltage (P = 0.579) between the groups. CONCLUSIONS: In the CAPLA cohort of patients, pattern of AF at first diagnosis did not influence post-ablation rate of AF recurrence or AF burden. (Catheter Ablation for persistent atrial fibrillation: A Multicentre randomised trial of Pulmonary vein isolation [PVI] vs PVI with posterior Left Atrial wall isolation [PWI]; ACTRN12616001436460).Rose Crowley, David Chieng, Louise Segan, Jeremy William, Hariharan Sugumar, Sandeep Prabhu, Aleksandr Voskoboinik, MBBS, Liang-Han Ling, Joseph B. Morton, f Geoffrey Lee, Alex J. McLellan, Michael Wong, Rajeev K. Pathak, Laurence Sterns, Matthew Ginks, Prashanthan Sanders, Peter M. Kistler, Jonathan M. Kalma
Sex specific outcomes following catheter ablation in persistent AF
No full textAvailable online 8 February 2024BACKGROUND Sex-specific outcomes after catheter ablation (CA) for atrial fibrillation (AF) have reported conflicting findings. OBJECTIVE We examined the impact of female sex on outcomes in patients with persistent AF (PsAF) from the Catheter Ablation for Persistent Atrial Fibrillation: A Multicentre Randomized Trial of Pulmonary Vein Isolation vs PVI with Posterior Left Atrial Wall Isolation (CAPLA) randomized trial. METHODS A total of 338 patients with PsAF were randomized to pulmonary vein isolation (PVI) or PVI with posterior wall isolation (PWI). The primary outcome was arrhythmia recurrence at 12 months. Clinical and electroanatomical characteristics, arrhythmia recurrence, and quality of life were compared between women and men. RESULTS Seventy-ninewomen (23.4%; PVI 37; PVI1PWI 42) and 259 men (76.6%; PVI 131; PVI1PWI 128) underwent AF ablation. Womenwere older {median age 70.4 (interquartile range [IQR] 64.8–74.6) years vs 64.0 (IQR 56.7–69.7) years; P < .001} and had more advanced left atrial electroanatomical remodeling. At 12 months, arrhythmia-free survival was lower in women (44.3% vs 56.8% in men; hazard ratio 1.44; 95% confidence interval 1.02–2.04; log-rank, P 5 .036). PWI did not improve arrhythmia-free survival at 12 months (hazard ratio 1.02; 95% confidence interval 0.74–1.40; log-rank, P 5 .711). The median AF burden was 0% in both groups (women: IQR 0.0%–2.2% vs men: IQR 0.0%–2.8%; P 5 .804). Health care utilization was comparable between women (36.7%) and men (30.1%) (P 5 .241); however, women were more likely to undergo a repeat procedure (17.7% vs 6.9%; P 5 .007). Women reported more severe baseline anxiety (average Hospital Anxiety and Depression Scale [HADS] anxiety score 7.5 6 4.9 vs 6.3 6 4.3 in men; P 5 .035) and AF-related symptoms (baseline Atrial Fibrillation Effect on Quality-of-Life Questionnaire [AFEQT] score 46.7 6 20.7 vs 55.96 23.0 inmen; P5 .002), with comparable improvements in psychological symptoms (change in HADS anxiety score 23.864.6 vs23.064.5; P5.152 (change inHADS depression score22.965.0 vs22.664.0; P5.542) and greater improvement in AFEQT score compared with men at 12 months (change in AFEQT score 145.9 6 23.1 vs 139.2 6 24.8; P 5 .048). CONCLUSION Women undergoing CA for PsAF report more significant symptoms and poorer quality of life at baseline than men. Despite higher arrhythmia recurrence and repeat procedures in women, the AF burden was comparably low, resulting in significant improvements in quality of life and psychological well-being after CA in both sexes.Louise Segan, David Chieng, Rose Crowley, Jeremy William, Hariharan Sugumar, Liang-Han Ling, Joshua Hawson, Sandeep Prabhu, Aleksandr Voskoboinik, M Joseph B. Morton, Geoffrey Lee, Laurence D. Sterns, Matthew Ginks, Prashanthan Sanders, Jonathan M. Kalman, Peter M. Kistle
Endocardial left ventricular pacing across the interventricular septum for cardiac resynchronization therapy: Clinical results of a pilot study
No full textBackground Cardiac resynchronization therapy (CRT) is an effective treatment for selected patients with heart failure, but it can be limited by the inability to place the left ventricular (LV) lead via the coronary sinus. Objective The purpose of this study was to develop an alternative approach, placing the LV lead endocardially via an interventricular septal puncture, and to assess the feasibility and safety of this technique. Methods All patients were anticoagulated with warfarin (international normalized ratio 2.5–3.5). A superior approach ventricular transseptal puncture using radiofrequency energy was performed. An active fixation pacing lead was delivered to the mapped site of latest electrical activation on the endocardial LV. Results Twenty patients were recruited, 15 with failed transvenous LV lead placement and 5 nonresponders to CRT. Mean (± SD) age was 67 ± 12, with 80% male, QRS duration 157 ± 14 ms, ischemic etiology 45%, New York Heart Association functional class 2.9 ± 0.4, and LV ejection fraction 28% ± 7%. The procedure was successful in all, with no serious complications. Clinical composite score improved at 6 months in 65% and worsened in 35%. LV ejection fraction improved >5% in 88%, from 28% ± 7% to 41% ± 9%. Six-minute walking distance improved >10% in 64%, from 248 ± 125 m to 316 ± 109 m. One patient suffered a lacunar ischemic stroke after 5 months with partial neurological recovery, associated with labile international normalized ratios. After 2.0 ± 1.0 years of follow-up, 3 patients died (2 pneumonia, 1 heart failure), and 2 patients suffered transient ischemic attacks. Conclusion LV endocardial pacing via interventricular septal puncture in patients for whom standard CRT is not possible is similarly effective and durable, with significant but potentially acceptable risks
Quantitative analysis of cardiac left ventricular variables obtained by MRI at 3 T : a pre- and post-contrast comparison
No full textShort-axis cine images are acquired during cardiac MRI in order to determine variables of cardiac left ventricular (LV) function such as ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV) and LV mass. In cardiac perfusion assessments this imaging can be performed in the temporal window between first pass perfusion and the acquisition of delayed enhancement images in order to minimise overall scanning time. The objective of this study was to compare pre- and post-contrast short-axis LV variables of 15 healthy volunteers using a two-dimensional cardiac-gated segmented cine true fast imaging with steady state precession sequence and a 3.0 T MRI unit in order to determine the possible effects of contrast agent on the calculated cardiac function variables. Image analysis was carried out using semi-automated software. The calculated mean LV mass was lower when derived from the post-contrast images, relative to those derived pre-contrast (102 vs 108.1 g, p<0.0001). Small but systematic significant differences were also found between the mean pre- and post-contrast values of EF (69.4% vs 68.7%, p<0.05), EDV (142.4 vs 143.7 ml, p<0.05) and ESV (44.2 vs 45.5 ml, p<0.005), but no significant differences in SV were identified. This study has highlighted that contrast agent delivery can influence the numerical outcome of cardiac variables calculated from MRI and this was particularly noticeable for LV mass. This may have important implications for the correct interpretation of patient data in clinical studies where post-contrast images are used to calculate LV variables, since LV normal ranges have been traditionally derived from pre-contrast data sets.Peer reviewe
35Power, lesion size index and oesophageal temperature alerts during atrial fibrillation ablation (PILOT-AF): a randomized study
No full textP1415Should radiofrequency power be titrated according to BMI in order to reduce esophageal injury during atrial fibrillation ablation?
No full textLong-term outcomes of catheter ablation for atrial fibrillation in octogenarians.
No full textBACKGROUND AND AIMS: Catheter ablation is superior to pharmacological therapy in controlling atrial fibrillation (AF). There are few data on the long-term outcome of AF ablation in octogenarian patients. This analysis aims to evaluate the outcome of AF ablation in octogenarians vs. younger patients. METHODS: In this retrospective study in 13 centres in the UK, France, and Switzerland, the long-term outcomes of 473 consecutive octogenarian patients undergoing ablation for AF were compared to 473 matched younger controls (median age 81.3 [80.0, 83.0] vs. 64.4 [56.5, 70.7] years, 54.3% vs. 35.1% females; p-value for both < 0.001). The primary endpoint was the recurrence of atrial arrhythmia after a blanking period of 90 days within 365 days of follow-up. RESULTS: Acute ablation success as defined as isolation of all pulmonary veins was achieved in 97% of octogenarians. Octogenarians experienced more procedural complications (11.4% vs 7.0%, p = 0.018). The median follow-up time was 281 [106, 365] days vs. 354 [220, 365] days for octogenarians vs. non-octogenarians (p < 0.001). Among octogenarians, 27.7% (131 patients) experienced a recurrence of atrial arrhythmia, in contrast to 23.5% (111 patients) in the younger group (odds ratio 1.49; 95% confidence interval 1.16-1.92; p = 0.002). In a multivariable regression model including gender, previous AF ablation, vascular disease, chronic kidney disease, CHA2DS2-VASc score, left atrial dilatation, and indwelling cardiac implantable electronic device, age above 80 remained an independent predictor of recurrence of arrhythmia. CONCLUSION: Ablation for AF is effective in octogenarians, but is associated with slightly higher procedural complication rate and recurrence of atrial arrhythmia than in younger patients
Procedural success of left ventricular lead placement for cardiac resynchronization therapy: a meta-analysis
No full textObjectives: The goal of this study was to assess the contemporary and historical success rates of transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy (CRT), their change over time, and the reasons for failure.Background:In selected patients, CRT improves morbidity and mortality, but the placement of the LV lead can be technically challenging.Methods:A literature search was used to identify all studies reporting success rates of LV lead placement for CRT via the coronary sinus (CS) route. A total of 164 studies were identified, and a meta-analysis was performed.Results:The studies included 29,503 patients: 74% (95% confidence interval [CI]: 72% to 76%) were male; their mean age was 66 years (95% CI: 65 to 67); their mean New York Heart Association functional class was 2.8 (95% CI: 2.7 to 2.9); the mean LV ejection fraction was 26% (95% CI: 25% to 28%); and the mean QRS duration was 155 ms (95% CI: 150 to 160). The overall rate of failure of implantation of an LV lead was 3.6% (95% CI: 3.1 to 4.3). The rate of failure in studies commencing before 2005 was 5.4% (95% CI: 4.4% to 6.5%), and from 2005 onward it was 2.4% (95% CI: 1.9% to 3.1%; p < 0.001). Causes of failure (reported for 39% of failures) also changed over time. Failure to cannulate and navigate the CS decreased from 53% to 30% (p = 0.01), and the absence of any suitable, acceptable vein increased from 39% to 64% (p = 0.007). The proportion of leads in a lateral or posterolateral final position (reported for 26% of leads) increased from 66% to 82% (p = 0.004).Conclusions:The reported rate of failure to place an LV lead via the CS has decreased steadily over time. A greater proportion of failures in recent studies are due to coronary venous anatomy that is unsuitable for this technique
89 Electromechanical interaction in patients undergoing cardiac resynchronisation therapy: comparison of intracardiac activation maps and early septal contraction in left bundle branch block
No full textIntroduction Early inward motion and thickening/thinning of the ventricular septum associated with left bundle branch block (LBBB) is known as the septal flash (SF). Correction of SF corresponds with CRT response. We hypothesise that electromechanical interactions induced by SF are associated with functional changes in conductivity and a “U-shaped” activation pattern. Characterising the spatio-temporal relationship between electrical and mechanical events may explain why patients with a SF respond to CRT. Methods 13 patients (63±10 years, 10 men) with severe heart failure (EF 22.8±5.8%) undergoing CRT underwent echocardiography and non-contact mapping (NCM) pre-implant. Presence and extent of a SF was defined visually and with M-mode and fused with NCM bull′s eye plots of endocardial activation patterns. LV dP/dtmax was measured during different pacing modes.Results Five patients had a large SF, four small SF and four no SF. Patients with large SF had areas of conduction block in non-infarcted regions whereas those with small or no SF did not (Abstract 89 figure 1). Patients with large SF had greater acute response to left ventricular (LV) and biventricular (BIV) pacing vs those with small/no SF (% increase dP/dt 28±14% vs 11±19% for LV pacing and 42±28% vs 22±21% for BIV pacing). The lines of conduction block disappeared after LV and BIV pacing, while remaining present with RV pacing (Abstract 89 figure 2). Abstract 89 figure 1 Patient with a large SF. Unipolar isochronal map with NCM electrograms showing fragmented signals (development of split potentials) indicating a reduction of conduction and inability to cross throughout the inferior region. The NCM mapping electrograms show the criteria used by Auricchio et al to define block, with the emergence of R-wave, smallest and earliest at the superior part of the block (where area of block begins) with largest negative peak. Bold white arrows on the electrogram indicate how the electrical activation spreads superiorly in a U-shape pattern leading to the development of split potentials. Abstract 89 figure 2 Activation maps of patient with a large SF. Row A, baseline with area of block and late anterior breakthrough. Row B, RV pacing showing the area of anterior block remains. Row C, BIV pacing. Functional conduction block has disappeared
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