9 research outputs found
A worldwide survey on incidence, management and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: The POTTER-AF study.
AIMS
Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management and outcome are sparse.
METHODS AND RESULTS
This international multicenter registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553,729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed at 214 centers in 35 countries. In 78 centers 138 patients (0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (p<0.0001)) were diagnosed with an oesophageal fistula. Periprocedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8%, and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) (odds ratio 7.463 (2.414, 23.072) p<0.001).
CONCLUSIONS
Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high
Efficacy of advanced pace-mapping technology for idiopathic premature ventricular complexes ablation
Timing and source of the maximum of the transthoracic impedance cardiogram (dZ/dt) in relation to the H-I-J complex of the longitudinal ballistocardiogram under gravity and microgravity conditions
The transthoracic impedance cardiogram (ICG)
and the acceleration ballistocardiogram (BCG) measured close
to the center of mass of the human body are generated by
changes of blood distribution. The transthoracic ICG is an
integrated signal covering the whole thorax and spatial
resolution is poor. Comparison between both signals can be
used to elucidate the source of the ICG signal. We recorded the
ECG, ICG, and BCG simultaneously in healthy subjects under
resting and microgravity conditions during parabolic flights.
The time interval between the R-peak of the ECG and the
maximum of the ICG (R-dZ/dtmax) and the time interval
between the R-peak of the ECG and the I-peak in the BCG (RI)
differed significantly (p<0.0001). The I-peak in the BCG
always occurred earlier during systole than dZ/dtmax. The
delay of dZ/dtmax ranged between 23 and 28 ms at rest and
was lowest under microgravity conditions (12±4 ms, p<0.02).
Our results suggest that both signals have different sources.
Combination of modern imaging techniques with classical non
invasive approaches to detect changes of blood distribution
may provide new insights into the complex interaction between
blood flow and mechanocardiographic signals like the BCG
Identification of repetitive atrial activation patterns in persistent atrial fibrillation by direct contact high-density electrogram mapping
Introduction: Recent studies have characterized drivers in persistent atrial fibrillation using automated algorithm detection with panoramic endocardial mapping by means of basket catheters. We aimed to identify repetitive atrial activation patterns (RAAPs) during ongoing atrial fibrillation (AF) based upon automated annotation of unipolar electrograms (EGMs) recorded with a high-density regional endocardial contact mapping catheter. Methods: In 14 persistent AF patients, high-resolution EGMs were recorded for 30 seconds at sequential PentaRay (Biosense Inc) positions covering the entire biatrial surface. All recordings were reviewed off-line with dedicated software allowing automated annotation of the local activation time of the unipolar fibrillatory EGMs (CARTOFINDER; Biosense Inc). RAAPs were defined as a consistent activation pattern (for â„3 consecutive beats) of either focal activity with centrifugal spread (RAAPfocal) or rotational activity across the PentaRay splines spanning the AF cycle length (RAAProtational). Results: A total of 498 PentaRay recordings were analyzed (35.6 ± 7.6 per patient). The number of PentaRay recordings displaying RAAP was 9.8 ± 3.1 per patient (range = 3-15), of which 2.4 ± 2.4 RAAProtational (range = 0-7), and 7.4 ± 4.4 RAAPfocal (range = 1-13). 77% of RAAPs portrayed focal firing. The median number of repetitions per 30 second recording was 11 (range = 3-225) per recording. RAAPs were observed both in the right atrium (RA) (35%) and left atrium (LA) (65%), with the majority being near the left PVs/appendage (35% of all RAAPs) and the superior vena cava/right appendage (23% of all RAAPs). Conclusion: High-resolution, sequential endocardial EGM-based mapping allows identification of RAAPs in persistent AF. In our series, focal firing was the most frequently observed pattern
Endoscopic evaluation of the esophagus after catheter ablation of atrial fibrillation using contiguous and optimized radiofrequency applications
Background: The incidence of endoscopically detected esophageal lesions after pulmonary vein isolation (PVI) is as high as 18%. Intraesophageal temperature rise (ITR) during ablation is a predictor of esophageal injury. Objective: The purpose of this study was to describe an ablation strategy aiming to enclose the pulmonary veins with contiguous, stable, and optimized radiofrequency applications (referred to as CLOSE-PVI). We evaluated esophageal and periesophageal injury with endoscopy in patients revealing ITR during CLOSE-PVI. Methods: Eighty-five patients with ITR during CLOSE-PVI underwent endoscopy of the esophagus (with ultrasound in 38 patients). PVI consisted of contact force (CF)-guided encircling of the veins using 35-W applications, respecting strict criteria of intertag distance (â€6 mm) and ablation index (AI; 550 arbitrary unit [au] anterior wall, 400 au posterior wall, 300 au if ITR >38.5°C). Results: Endoscopy was performed 9 ± 4 days after PVI. At the posterior wall, median power was 35 W [interquartile range (IQR) 35â35], application time 18 ± 5 seconds, CF 13 ± 6g, and AI 403 ± 38 au. A median of 5 applications [IQR 4â7] per patient over a length of 21.8 ± 6.8 mm resulted in ITR >38.5°C (median 39.9°C, IQR 39.2°Câ41.2°C, range 38.6°Câ50.0°C). For these applications, median power was 35 W [IQR 30â35], application time 14 ± 3 seconds, CF 12 ± 5g, and AI 351 ± 38 au. The incidence of esophageal erythema/erosion on endoscopy was 1 of 85 (1.2%) and of ulceration was 0 of 85 (0%). The incidence of mediastinal or esophageal injury on ultrasound was 0 of 38 (0%). Conclusion: The occurrence of esophageal or periesophageal injury after CLOSE-PVI is markedly low (1.2%). Absence of esophageal ulceration in patients with ITR suggests that this strategy of delivering contiguous, relatively high-power, and short-duration radiofrequency applications at the posterior wall is safe
Evaluation of higher power delivery during RF pulmonary vein isolation using optimized and contiguous lesions
Aims: âCLOSEâ-guided pulmonary vein isolation (PVI) is based on contiguous (â€6 mm) and optimized radiofrequency (RF) ablation lesions (ablation index [AI] â„ 400 posteriorly and â„ 550 anteriorly]. However, the optimal RF power to reach the desired AI is unknown. Therefore we evaluated the efficiency of an ablation strategy using higher power (40 W) during a first âCLOSEâ-guided PVI. Methods: Eighty consecutive patients undergoing âCLOSEâ-guided PVI for symptomatic paroxysmal atrial fibrillation were ablated with 40 W (group A). Results were compared with 105 consecutive patients enrolled in the âCLOSE to CUREâ-study and were ablated using the same protocol with 35 W (group B). Results: In group A, ablation was associated with shorter ablation procedure time (91 vs 111 minutes; P .733) were similar in both groups (groups A and B, respectively). No complications occurred. In group A, a gastroscopyâperformed in five patients with esophageal temperature rise more than 42°Câdid not reveal any esophageal lesion. Postprocedural recurrence of atrial tachyarrhythmia at 1 year was not significantly different between both groups. Conclusions: Using the âCLOSEâ-protocol, increased power increases the efficiency of PVI without compromising patients' safety
Predictors of recurrence after durable pulmonary vein isolation for paroxysmal atrial fibrillation
AIMS: Catheter ablation of paroxysmal atrial fibrillation (AF) reduces AF recurrence, AF burden, and improves quality of life. Data on clinical and procedural predictors of arrhythmia recurrence are scarce and are flawed by the high rate of pulmonary vein reconnection evidenced during repeat procedures after pulmonary vein isolation (PVI). In this study, we identified clinical and procedural predictors for AF recurrence 1 year after CLOSE-guided PVI, as this strategy has been associated with an increased PVI durability. METHODS AND RESULTS: Patients with paroxysmal AF, who received CLOSE-guided PVI and who participated in a prospective trial in our centre, were included in this study. Uni- and multivariate models were plotted to find clinical and procedural predictors for AF recurrence within 1 year. Three hundred twenty-five patients with a mean age of 63âyears (CHA2DS2VASc 1 [1-3], left atrium diameter 41â±â6 mm) were included. About 60.9% were male individuals. After 1 year, AF recurrence occurred in 10.5% of patients. In a binary logistic regression analysis, the diagnosis-to-ablation time (DAT) was found to be the strongest predictor of AF recurrence (Pâ=â0.011). Diagnosis-to-ablation time â„1âyear was associated with a nearly two-fold increased risk for developing AF recurrence. CONCLUSION: The DAT is the most important predictor of arrhythmia recurrence in low-risk patients treated with durable pulmonary vein isolation for paroxysmal AF. Whether reducing the DAT could improve long-term outcomes should be investigated in another trial
A worldwide survey on incidence, management and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation:The POTTER-AF study
AIMS: Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management and outcome are sparse.METHODS AND RESULTS: This international multicenter registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553,729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed at 214 centers in 35 countries. In 78 centers 138 patients (0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (p<0.0001)) were diagnosed with an oesophageal fistula. Periprocedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8%, and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) (odds ratio 7.463 (2.414, 23.072) p<0.001).CONCLUSIONS: Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.</p