34 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
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
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
Endocardial left ventricular pacing for cardiac resynchronization: systematic review and meta-analysis.
No full textAims Endocardial left ventricular (LV) pacing for Cardiac Resynchronization Therapy has been proposed as an alternative to conventional LV lead placement via the coronary sinus. In order to assess the relative benefits and risks of this technique, we have performed a meta-analysis of published reports. Methods and Results A systemic search was performed using online databases to identify studies of lead-based endocardial pacing. A random-effects meta-analysis was performed, to assess the rate of complications and clinical response (defined as >_1 decrease in NYHA class). We selected 23 studies, including 384 patients. The trans-atrial septal technique was used in 20 studies, 1 used the trans-ventricular apical technique, and 2 used the trans-ventricular septal technique. Mean age was 66 years, male 66%, EF 26%, NYHA class 3.0. Procedural success rates were over 95% in all studies. Clinical response was reported by 16 studies for 262 patients, giving a response estimate of 82% (95% CI 71–89%). There was significant heterogeneity, and response in the only large study was 59%. Thromboembolic (TE) complications were reported by all studies, over 22 ±32 months follow up. The rate of stroke was 2.5 events per 100 patient years (95% CI 1.5–4.3), and TIA 2.6 (1.1–6.1). The mortality rate was 4.5 (1.5–13.6) per 100 patient years. Conclusions LV endocardial pacing appears to be a viable technique when conventional lead placement is not possible. Response rates were heterogeneous but comparable with conventional CRT. There is likely to be a small increase over expected rates of stroke, although included patients were high risk
The Role of Adenosine in Pulmonary Vein Isolation: A Critical Review
No full textThe cornerstone of atrial fibrillation (AF) ablation is pulmonary vein isolation (PVI), which can be achieved in more than 95% of patients at the end of the procedure. However, AF recurrence rates remain high and are related to recovery of PV conduction. Adenosine testing is used to unmask dormant pulmonary vein conduction (DC). The aim of this study is to review the available literature addressing the role of adenosine testing and determine the impact of ablation at sites of PV reconnection on freedom from AF. Adenosine infusion, by restoring the excitability threshold, unmasks reversible injury that could lead to recovery of PV conduction. The studies included in this review suggest that adenosine is useful to unmask nontransmural lesions at risk of reconnection and that further ablation at sites of DC is associated with improvement in freedom from AF. Nevertheless it has been demonstrated that adenosine is not able to predict all veins at risk of later reconnection, which means that veins without DC are not necessarily at low risk. The role of the waiting period in the setting of adenosine testing has also been analyzed, suggesting that in the acute phase adenosine use should be accompanied by enough waiting time
The Role of Adenosine in Pulmonary Vein Isolation: A Critical Review
No full textThe cornerstone of atrial fibrillation (AF) ablation is pulmonary vein isolation (PVI), which can be achieved in more than 95% of patients at the end of the procedure. However, AF recurrence rates remain high and are related to recovery of PV conduction. Adenosine testing is used to unmask dormant pulmonary vein conduction (DC). The aim of this study is to review the available literature addressing the role of adenosine testing and determine the impact of ablation at sites of PV reconnection on freedom from AF. Adenosine infusion, by restoring the excitability threshold, unmasks reversible injury that could lead to recovery of PV conduction. The studies included in this review suggest that adenosine is useful to unmask nontransmural lesions at risk of reconnection and that further ablation at sites of DC is associated with improvement in freedom from AF. Nevertheless it has been demonstrated that adenosine is not able to predict all veins at risk of later reconnection, which means that veins without DC are not necessarily at low risk. The role of the waiting period in the setting of adenosine testing has also been analyzed, suggesting that in the acute phase adenosine use should be accompanied by enough waiting time
The Role of Adenosine in Pulmonary Vein Isolation: A Critical Review
No full textThe cornerstone of atrial fibrillation (AF) ablation is pulmonary vein isolation (PVI), which can be achieved in more than 95% of patients at the end of the procedure. However, AF recurrence rates remain high and are related to recovery of PV conduction. Adenosine testing is used to unmask dormant pulmonary vein conduction (DC). The aim of this study is to review the available literature addressing the role of adenosine testing and determine the impact of ablation at sites of PV reconnection on freedom from AF. Adenosine infusion, by restoring the excitability threshold, unmasks reversible injury that could lead to recovery of PV conduction. The studies included in this review suggest that adenosine is useful to unmask nontransmural lesions at risk of reconnection and that further ablation at sites of DC is associated with improvement in freedom from AF. Nevertheless it has been demonstrated that adenosine is not able to predict all veins at risk of later reconnection, which means that veins without DC are not necessarily at low risk. The role of the waiting period in the setting of adenosine testing has also been analyzed, suggesting that in the acute phase adenosine use should be accompanied by enough waiting time
Multi-site left ventricular pacing as a potential treatment for patients with postero-lateral scar: insights from cardiac magnetic resonance imaging and invasive haemodynamic assessment
No full textAims Multi-site left ventricular (LV) pacing may be superior to single-site stimulation in correcting dyssynchrony and avoiding areas of myocardial scar. We sought to characterize myocardial scar using cardiac magnetic resonance imaging (CMR). We aimed to quantify the acute haemodynamic response to single-site and multi-site LV stimulation and to relate this to the position of the LV leads in relation to myocardial scar. MethodsTwenty patients undergoing cardiac resynchronization therapy had implantation of two LV leads. One lead (LV1) was positioned in a postero-lateral vein, the second (LV2) in a separate coronary vein. LV dP/dtmax was recorded using a pressure wire during stimulation at LV1, LV2, and both sites simultaneously (LV1 + 2). Patients were deemed acute responders if ΔLV dP/dtmax was ≥10%. Cardiac magnetic resonance imaging was performed to assess dyssynchrony as well as location and burden of scar. Scar anatomy was registered with fluoroscopy to assess LV lead position in relation to scar. ResultsLV dP/dtmax increased from 726 ± 161 mmHg/s in intrinsic rhythm to 912 ± 234 mmHg/s with LV1, 837 ± 188 mmHg/s with LV2, and 932 ± 201 mmHg/s with LV1 and LV2. Nine of 19 (47%) were acute responders with LV1 vs. 6/19 (32%) with LV2. Twelve of 19 (63) were acute responders with simultaneous LV1 + 2. Two of three patients benefitting with multi-site pacing had the LV1 lead positioned in postero-lateral scar. ConclusionMulti-site LV pacing increased acute response by 16 vs. single-site pacing. This was particularly beneficial in patients with postero-lateral scar identified on CMR. © The Author 2011
208 Fusion of MR-derived anatomical and late enhancement image data with ablation mapping for verification of lesion delivery for cardiac radio-frequency ablation
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