Outcomes of long-standing persistent atrial fibrillation ablation: A systematic review

BackgroundAblation of long-standing persistent atrial fibrillation (AF) is highly variable, with differing techniques and outcomes.ObjectiveThe purpose of this study was to undertake a systematic review of the literature with regard to the impact of ablation technique on the outcomes of long-standing persistent AF ablation.MethodsA systematic search of the contemporary English scientific literature (from January 1, 1990 to June 1, 2009) in the PubMed database identified 32 studies on persistent/long-standing persistent or long-standing persistent AF ablation (including four randomized controlled trials). Data on single-procedure, drug-free success, multiple procedure success, and pharmaceutically assisted success at longest follow-up were collated.ResultsFour studies performed pulmonary vein isolation alone (21%-22% success). Four studies performed pulmonary vein antrum ablation with isolation (PVAI; n = 2; 38%-40% success) or without confirmed isolation (PVA; n = 2; 37%-56% success). Ten studies performed linear ablation in addition to PVA (n = 5; 11%-74% success) or PVAI (n = 5; 38%-57% success). Three studies performed posterior wall box isolation (n = 3; 44%-50% success). Five studies performed complex fractionated atrial electrogram ablation (n = 5; 24%-63% success). Six studies performed complex fractionated atrial electrogram ablation as an adjunct to PVA (n = 2; 50%-51% success), PVAI (n = 3; 36%-61% success), or PVAI and linear (n = 1; 68% success) ablation. Five studies performed the stepwise ablation approach (38%-62% success).ConclusionThe variation in success within and between techniques suggests that the optimal ablation technique for long-standing persistent AF is unclear. Nevertheless, long-standing persistent AF can be effectively treated with a composite of extensive index catheter ablation, repeat procedures, and/or pharmaceuticals.Anthony G. Brooks, Martin K. Stiles, Julien Laborderie, Dennis H. Lau, Pawel Kuklik, Nicholas J. Shipp, Li-Fern Hsu, and Prashanthan Sandershttp://www.elsevier.com/wps/find/journaldescription.cws_home/702333/description#descriptio

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

Du Rôle des sens en médecine, par J.-F. Laborderie,...

Avec mode text

Accuracy and clinical outcomes of CT image integration with Carto-Sound compared to electro-anatomical mapping for atrial fibrillation ablation: A randomized controlled study

BackgroundCarto-Sound integrates 2D intra-cardiac ultrasound imaging into a 3D environment to allow left atrial mapping from the right atrium without fluoroscopic assistance. We conducted an open randomized controlled study to compare procedural, clinical and accuracy parameters between CT integrated Carto-Sound and electro-anatomic mapping (EAM) for AF ablation.MethodsSixty index AF ablation patients were randomized equally to either the Carto-Sound or EAM mapping/navigation for their procedure performed at a single institution. Procedure and X-ray times, X-ray dose, navigational accuracy and clinical success were assessed. The study was powered to the primary outcome of fluoroscopy time.ResultsTotal procedure (232 ± 60 vs 223 ± 48 min; p = 0.51), ablation (p = 0.84) and mapping times (p = 0.11) were similar in each group. In contrast, Carto-Sound reduced total X-ray time (65 ± 18 vs 51 ± 12 min; p = 0.001), via a reduction in both mapping (p0.17) compared to EAM. Ultra-sound assisted 3D mapping did not improve single procedure drug free clinical success (EAM: 13/30 [43%] vs Carto-Sound: 15/30 [50%]) at a mean of 13 ± 5 months (p = 0.79).ConclusionsIn the context of long left atrial procedures with high radiation doses, reduced X-ray and left atrial access times using CT integrated Carto-Sound mapping/navigation may have implications for patients and laboratory staff, albeit at an extra financial cost and the requirement of an additional access site for a right sided catheter.Trial registration numberACTRN12612000089831.Anthony G. Brooks, Lauren Wilson, Nicholas H. Chia, Dennis H. Lau, Muayad Alasady, Darryl P. Leong, Julien Laborderie, Kurt C. Roberts-Thomson, Glenn D. Young, Jonathan M. Kalman, Prashanthan Sander

Flutter localized to the anterior left atrium after catheter ablation of atrial fibrillation

The definitive version is available at www.blackwell-synergy.comIntroductionOrganized atrial arrhythmias following atrial fibrillation (AF) ablation are typically due to recovered pulmonary vein (PV) conduction or reentry at incomplete ablation lines. We describe the role of nonablated anterior left atrium (LA) in arrhythmias observed after AF ablation.MethodsA total of 275 consecutive patients with paroxysmal (n = 200) or chronic (n = 75) AF had PV isolation with/without additional linear ablation at the mitral isthmus (n = 106), LA roof (n = 23), or both (n = 88). Organized arrhythmias occurring after ablation were evaluated utilizing activation and entrainment mapping.ResultsFourteen patients (11 female, 65 +/- 13 years, 10 chronic AF, 10 structural heart disease) demonstrated tachycardia localized to the anterior LA, an area not targeted by prior ablation. Eight had ECG features during sinus rhythm suggestive of impaired anterior LA conduction at baseline. These arrhythmias demonstrated a distinctive ECG flutter morphology in 7 of 10 (70%) with discrete -/+ or +/-/+ aspect in inferior leads. Mapping the anterior LA revealed electrograms spanning the entire tachycardia cycle length (325 +/- 125 msec). Entrainment was possible in all with a postpacing interval exceeding the tachycardia cycle length by 9 +/- 10 msec. Electroanatomic mapping in 6 demonstrated small reentrant circuits rotating clockwise in 4 and counterclockwise in 2. Low-amplitude, fractionated mid-diastolic potentials with long duration (200 +/- 80 msec) occupying 63 +/- 22% of the cycle length were targeted for ablation resulting in termination and subsequent noninducibility.ConclusionOrganized arrhythmias occurring after AF ablation can be due to reentrant circuits localized to the anterior LA, predominantly in females with chronic AF, structural heart disease, and abnormal atrial conduction. They are characterized by a distinctive surface ECG and highly responsive to RF ablation at the slow conduction area.Pierre Jaîs, Prashanthan Sanders, Li-Fern Hsu, Mélèze Hocini, Fréderic Sacher, Yoshihide Takahashi, Martin Rotter, Thomas Rostock, Pierre Bordachar, Sylvain Reuter, Julien Laborderie, Jacques Clémenty, and Michel Haîssaguerr

Impact of Pacing Site on QRS Duration and Its Relationship to Hemodynamic Response in Cardiac Resynchronization Therapy for Congestive Heart Failure

Cardiolog