Catheter ablation of symptomatic postoperative atrial arrhythmias after epicardial surgical disconnection of the pulmonary veins and left atrial appendage ligation in patients with atrial fibrillation

OBJECTIVES: Minimally invasive thoracoscopic epicardial pulmonary vein isolation (MIPI) has an important role in the surgical treatment of atrial fibrillation (AF). However, the management of recurrent atrial arrhythmias after MIPI and long-term success rate of catheter ablation have not been well studied. METHODS: Electrophysiological study was performed in 23 patients, 378 +/- 282 days after MIPI surgery, because of recurrent symptomatic atrial arrhythmias. RESULTS: A total of 20 patients presented with paroxysmal and persistent AF, 2 patients had a combination of AF and atrial tachycardia (AT) and 1 patient had a combination of AF and atrial flutter. All patients showed pulmonary vein (PV) reconnection. ATs were micro-re-entry PV-related ATs and atrial flutter was cavotricuspid isthmus dependent. Eighteen of 23 patients (78.3%) were free of atrial arrhythmias after one catheter ablation procedure at a mean follow-up of 50 +/- 16 months. Three patients underwent a second ablation procedure for recurrent AF and macro-re-entry left atrial flutter. Eventually 20 of 23 patients (87%) remained free of atrial arrhythmias after a mean of 1.1 +/- 0.3 ablation procedures. CONCLUSIONS: Catheter ablation of recurrent atrial arrhythmias following MIPI for paroxysmal and persistent AF is a feasible and effective treatment with a good long-term success rate. Reconnection of PVs accounts for most recurrences

Ablation of focal atrial tachycardia from the non-coronary aortic cusp: case series and review of the literature

Item does not contain fulltextAIMS: Focal atrial tachycardia successfully ablated from the non-coronary cusp (NCC) is rare. Our aim was to describe the characteristics of mapping and ablation therapy of NCC focal atrial tachycardias and to provide a comprehensive review of the literature. METHODS AND RESULTS: Seven patients (age 40 +/- 9 years) with symptomatic, drug-refractory atrial tachycardia were referred for electrophysiological study. Extensive right and left atrial mapping revealed atrial tachycardia near His in all patients but either failed to identify a successful ablation site or radiofrequency applications only resulted in temporary termination of the tachycardia. Mapping and ablation of the NCC were performed retrogradely via the right femoral artery. Mapping of the NCC demonstrated earliest atrial activation during atrial tachycardia 38 +/- 14 ms (ranging 17-56 ms) before the onset of the P-wave. Earliest atrial activation in the NCC was earlier than earliest activation in the right atrium and left atrium in all patients. The P-wave morphology was predominantly negative in the inferior leads and biphasic in leads V1 and V2. The tachycardia was successfully terminated by radiofrequency application in 10 +/- 6 s (2-16 s), without complications. All patients were free of symptoms during a follow-up of 19 +/- 9 months. Literature search revealed 18 reports (91 patients) describing NCC focal atrial tachycardia, with 99% long-term ablation success with a 1% complication rate. CONCLUSION: Symptomatic focal atrial tachycardia near His may originate from the NCC and can be treated safely and effectively with radiofrequency ablation

Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF)

BACKGROUND: Metoprolol can improve haemodynamics in chronic heart failure, but survival benefit has not been proven. We investigated whether metoprolol controlled release/extended release (CR/XL) once daily, in addition to standard therapy, would lower mortality in patients with decreased ejection fraction and symptoms of heart failure. METHODS: We enrolled 3991 patients with chronic heart failure in New York Heart Association (NYHA) functional class II-IV and with ejection fraction of 0.40 or less, stabilised with optimum standard therapy, in a double-blind randomised controlled study. Randomisation was preceded by a 2-week single-blind placebo run-in period. 1990 patients were randomly assigned metoprolol CR/XL 12.5 mg (NYHA III-IV) or 25.0 mg once daily (NYHA II) and 2001 were assigned placebo. The target dose was 200 mg once daily and doses were up-titrated over 8 weeks. Our primary endpoint was all-cause mortality, analysed by intention to treat. FINDINGS: The study was stopped early on the recommendation of the independent safety committee. Mean follow-up time was 1 year. All-cause mortality was lower in the metoprolol CR/XL group than in the placebo group (145 [7.2%, per patient-year of follow-up]) vs 217 deaths [11.0%], relative risk 0.66 [95% CI 0.53-0.81]; p=0.00009 or adjusted for interim analyses p=0.0062). There were fewer sudden deaths in the metoprolol CR/XL group than in the placebo group (79 vs 132, 0.59 [0.45-0.78]; p=0.0002) and deaths from worsening heart failure (30 vs 58, 0.51 [0.33-0.79]; p=0.0023). INTERPRETATION: Metoprolol CR/XL once daily in addition to optimum standard therapy improved survival. The drug was well tolerated