High-density mapping of the average complex interval helps localizing atrial fibrillation drivers and predicts catheter ablation outcomes

BackgroundPersistent Atrial Fibrillation (PersAF) electrogram-based ablation is complex, and appropriate identification of atrial substrate is critical. Little is known regarding the value of the Average Complex Interval (ACI) feature for PersAF ablation.ObjectiveUsing the evolution of AF complexity by sequentially computing AF dominant frequency (DF) along the ablation procedure, we sought to evaluate the value of ACI for discriminating active drivers (AD) from bystander zones (BZ), for predicting AF termination during ablation, and for predicting AF recurrence during follow-up.MethodsWe included PersAF patients undergoing radiofrequency catheter ablation by pulmonary vein isolation and ablation of atrial substrate identified by Spatiotemporal Dispersion or Complex Fractionated Atrial Electrograms (>70% of recording). Operators were blinded to ACI measurement which was sought for each documented atrial substrate area. AF DF was measured by Independent Component Analysis on 1-minute 12-lead ECGs at baseline and after ablation of each atrial zone. AD were differentiated from BZ either by a significant decrease in DF (>10%), or by AF termination. Arrhythmia recurrence was monitored during follow-up.ResultsWe analyzed 159 atrial areas (129 treated by radiofrequency during AF) in 29 patients. ACI was shorter in AD than BZ (76.4 ± 13.6 vs. 86.6 ± 20.3 ms; p = 0.0055), and mean ACI of all substrate zones was shorter in patients for whom radiofrequency failed to terminate AF [71.3 (67.5–77.8) vs. 82.4 (74.4–98.5) ms; p = 0.0126]. ACI predicted AD [AUC 0.728 (0.629–0.826)]. An ACI < 70 ms was specific for predicting AD (Sp 0.831, Se 0.526), whereas areas with an ACI > 100 ms had almost no chances of being active in AF maintenance. AF recurrence was associated with more ACI zones with identical shortest value [3.5 (3–4) vs. 1 (0–1) zones; p = 0.021]. In multivariate analysis, ACI < 70 ms predicted AD [OR = 4.02 (1.49–10.84), p = 0.006] and mean ACI > 75 ms predicted AF termination [OR = 9.94 (1.14–86.7), p = 0.038].ConclusionACI helps in identifying AF drivers, and is correlated with AF termination and AF recurrence during follow-up. It can help in establishing an ablation plan, by prioritizing ablation from the shortest to the longest ACI zone

Volume overload impact on 3D right ventricular shape and strain: comparative analysis of tetralogy of Fallot and atrial septal defect patients

International audienc

Three-dimensional right-ventricular regional deformation and survival in pulmonary hypertension

International audienceBackground: Survival in pulmonary hypertension (PH) relates to right ventricular (RV) function. However, the RV unique anatomy and structure limit 2D analysis and its regional 3D function has not been studied yet. The aim of this study was to assess the implications of global and regional 3D RV deformation on clinical condition and survival in adults with PH and healthy controls.Methods and Results: We collected a prospective longitudinal cohort of 104 consecutive PH patients and 34 healthy controls between September 2014 and December 2015. Acquired 3D transthoracic RV echocardiographic sequences were analysed by semi- automatic software (TomTec 4D RV-Function 2.0). Output meshes were post-processed to extract regional motion and deformation. Global and regional statistics provided deformation patterns for each subgroup of subjects.RV lateral and inferior regions showed the highest deformation. In PH patients, RV global and regional motion and deformation (both circumferential, longitudinal and area strain) were affected in all segments (p-18% was the most powerful RV function parameter, identifying patients with a 48%-increased risk of death (AUC 0.83 [0.74-0.90], p<0.001).Conclusions: RV strain patterns gradually worsen in PH patients and provide independent prognostic information in this population

Technological advances in cardiac pacing and defibrillation

Since more than a half century, cardiac pacing and defibrillation represent a field in constant evolution, and they have shown some great technological advances from its conception to its methods of insertion. In this review, the recent developments about the accesses for pacemakers and ICD will be described: the axillary and the femoral vein. The His bundle pacing and the advantages of the entirely subcutaneous defibrillator will also be presented

Severe Periprocedural Complications After Ablation for Atrial Fibrillation: An International Collaborative Individual Patient Data Registry.

BACKGROUND Catheter ablation for atrial fibrillation (AF) including pulmonary vein isolation and possibly further substrate ablation is the most common electrophysiological procedure. Severe complications are uncommon, but their detailed assessment in a large worldwide cohort is lacking. OBJECTIVES The aim of this study was to determine the incidence of periprocedural severe complications and to provide a detailed characterization of the diagnostic evaluation and management of these complications in patients undergoing AF ablation. METHODS Individual patient data were collected from 23 centers worldwide. Limited data were collected for all patients who underwent catheter ablation, and an expanded series of data points were collected for patients who experienced severe complications during periprocedural follow-up. Incidence, predictors, patient characteristics, management details, and overall outcomes of patients who experienced ablation-related complications were investigated. RESULTS Data were collected from 23 participating centers at which 33,879 procedures were performed (median age 63 years, 30% women, 71% radiofrequency ablations). The incidence of severe complications (n = 271) was low (tamponade 6.8‰, stroke 0.97‰, cardiac arrest 0.41‰, esophageal fistula 0.21‰, and death 0.21‰). Age, female sex, a dilated left atrium, procedure duration, and the use of radiofrequency energy were independently associated with the composite endpoint of all severe complications. Among patients experiencing tamponade, 13% required cardiac surgery. Ninety-three percent of patients with complications were discharged directly home after a median length of stay of 5 days (Q1-Q3: 3-7 days). CONCLUSIONS This large worldwide collaborative study highlighted that tamponade, stroke, cardiac arrest, esophageal fistula, and death are rare after AF ablation. Older age, female sex, procedure duration, a dilated left atrium, and the use of radiofrequency energy were associated with severe complications in this multinational cohort. One in 8 patients with tamponade required cardiac surgery

Paramètres de complexité des signaux de la fibrillation atriale persistante pour discrimination des zones arythmogènes actives au cours de l'ablation par radiofréquence

Atrial fibrillation (AF) is the most frequent arrhythmia, and is responsible for significant morbidity and mortality. Its interventional treatment requires electrical isolation of the pulmonary veins, and usually additional ablation of specific atrial zones is performed in the setting of persistent AF. Persistent AF ablation based on intracardiac electrograms analysis is complex, and appropriate identification of atrial substrate is critical. Several signal parameters have been used for non-invasively characterizing AF complexity, and are linked to prognosis after treatment. Among them, the Fibrillatory Wave Amplitude (FWA) has been described as a non-invasive marker AF complexity, which seems to predict catheter ablation outcome. However, actual determinants of FWA remain incompletely understood. In this work, we sought to assess the respective implications of anatomical atrial substrate and AF spectral characteristics for FWA. We also analyzed the evolution of AF dominant frequency (DF) during radiofrequency ablation of persistent AF for identifying atrial zones playing a role in AF maintenance, and we performed correlations with readily accessible electrophysiological measures for helping the electrophysiologist in targeting appropriate substrate zones. We included 29 Persistent AF patients undergoing radiofrequency catheter ablation by pulmonary vein isolation and ablation of atrial substrate identified by Spatiotemporal Dispersion or Complex Fractionated Atrial Electrograms (>70% of recording). FWA was measured on 1-minute ECG by TQ concatenation in Lead I, V1, V2 and V5 at baseline and immediately before AF termination. AF DF was measured by Independent Component Analysis on 1-minute 12-Leads ECGs at baseline and after ablation of each atrial zone. Active drivers (AD) were differentiated from bystander zones (BZ) either by a significant decrease in DF (>10%), or by AF termination. FWA evolution during ablation was compared to that of AF DF. FWA was compared to the extent of endocardial low-voltage areas, to the surface of healthy left atrial tissue, and to P-wave amplitude in sinus rhythm. Predictive value of FWA for AF recurrence during follow-up was assessed. For predicting AD vs. BZ, several electrophysiological characteristics were assessed, such as the Average Complex Interval (ACI) which allows automated measurement of the mean local endocardial activation cycle. We found that FWA remained stable along ablation procedure with comparable values at baseline and before AF termination, whereas DF significantly decreased. FWA in V5 was strongly correlated with the surface of healthy left atrial tissue. FWA showed moderate to strong correlation to P-wave amplitude in all leads. Also, FWA did not predict AF recurrence during the follow-up. Over the 159 analyzed atrial areas, ACI was shorter in AD than BZ, and mean ACI of all substrate zones was shorter in patients for whom radiofrequency failed to terminate AF. AF recurrence was associated with more ACI zones with identical shortest value. In multivariate analysis, ACI75 ms predicted AF termination. These findings suggest that FWA is unrelated to AF complexity but is mainly determined by the amount of viable atrial myocytes; therefore, FWA should only be referred as a marker of atrial tissue pathology. Also, ACI helps in identifying AF drivers, and is correlated with AF termination and AF recurrence during follow-up.La fibrillation atriale (FA) est l’arythmie la plus fréquente, et est responsable d’une morbidité et d’une mortalité significative. L’ablation de la FA persistante basée sur l’analyse des électrogrammes intracardiaques est complexe, et l’identification correcte du substrat atrial de la FA est primordiale. Différents paramètres du signal ont été utilisés pour caractériser la complexité de la FA de manière non invasive, et sont reliés au pronostic après traitement. Parmi eux, l’amplitude de l’onde fibrillatoire (FWA) sur l’électrocardiogramme (ECG) de surface a été décrite comme un marqueur non invasif de la complexité de la FA, qui semble prédire les résultats de l’ablation. Cependant, les déterminants de la FWA restent incomplètement compris. Dans ce travail, nous avons voulu évaluer les implications respectives du substrat anatomique atrial et des caractéristiques spectrales de la FA sur la FWA. Nous avons également analysé l’évolution de la fréquence dominante (dominant frequency, DF) de la FA au cours de l’ablation par radiofréquence de la FA persistante pour identifier les zones atriales jouant un rôle dans le maintien de l’arythmie, et nous avons effectué des corrélations avec des mesures électrophysiologiques directement accessibles au rythmologue pendant l’intervention pour aider à définir les cibles atriales appropriées. Nous avons inclus 29 patients ablatés de FA persistante par radiofréquence, avec isolation des veines pulmonaires et ablation du substrat atrial identifié par dispersion spatiotemporelle ou électrogrammes fragmentés complexes (>70% de l’enregistrement). La FWA était mesurée sur des ECG d’une minute par concaténation des intervalles TQ sur les dérivations DI, V1, V2 et V5 à l’état basal et immédiatement avant arrêt de la FA. La DF de la FA était mesurée sur les composantes indépendantes déduites des ECG d’une minute à l’état basal et après ablation de chaque zone atriale. Les drivers actifs (active drivers, AD) étaient différentiés des zones neutres (bystander zones, BZ) soit par une diminution significative de la DF (>10%), soit par arrêt de la FA. L’évolution de la FWA au cours de l’ablation a été comparée à celle de la DF. La FWA a été comparée à l’étendue des zones de bas voltage atriales, à la surface de tissu atrial sain, et à l’amplitude de l’onde P en rythme sinusal. La valeur prédictive de la FWA pour la récidive de la FA a été évaluée. Pour identifier les AD vs. BZ, plusieurs caractéristiques électrophysiologiques ont été évalués comme l’Average Complex Interval (ACI), permettant une mesure automatisée du cycle moyen entre deux activations locales endocardiques. Nous avons trouvé que la FWA restait stable au cours de l’ablation avec des valeurs comparables à l’état basal et avant arrêt de la FA, alors que la DF diminuait significativement. La FWA sur V5 était fortement corrélée à la surface de tissu atrial sain. La FWA démontrait une corrélation modérée à forte avec l’amplitude de l’onde P dans toutes les dérivations. Egalement, la FWA ne prédisait pas la récidive de FA durant le suivi. Sur les 159 zones atriales évaluées, l’ACI était plus court pour les AD que les BZ, et l’ACI moyen de toutes les zones de substrat était plus court chez les patients chez qui la radiofréquence échouait à réduire la FA. La récidive de la FA était associée avec plus de zones ayant un ACI similaire à l’ACI le plus court du patient. En analyse multivariée, un ACI 75 ms prédisait un arrêt de la FA durant la procédure. Ces résultats suggèrent que la FWA n’a pas de lien direct avec la complexité de la FA mais est surtout déterminée par la quantité de tissu atrial viable ; de ce fait, la FWA devrait uniquement être considérée comme un marqueur de pathologie du tissu atrial. Egalement, l’ACI aide à identifier les drivers de la FA, et est corrélé avec l’arrêt de la FA et la récidive de la FA durant le suivi

Active arrhythmogenic zone identification in persistent atrial fibrillation using complexity parameters during radiofrequency catheter ablation

La fibrillation atriale (FA) est l’arythmie la plus fréquente, et est responsable d’une morbidité et d’une mortalité significative. L’ablation de la FA persistante basée sur l’analyse des électrogrammes intracardiaques est complexe, et l’identification correcte du substrat atrial de la FA est primordiale. Différents paramètres du signal ont été utilisés pour caractériser la complexité de la FA de manière non invasive, et sont reliés au pronostic après traitement. Parmi eux, l’amplitude de l’onde fibrillatoire (FWA) sur l’électrocardiogramme (ECG) de surface a été décrite comme un marqueur non invasif de la complexité de la FA, qui semble prédire les résultats de l’ablation. Cependant, les déterminants de la FWA restent incomplètement compris. Dans ce travail, nous avons voulu évaluer les implications respectives du substrat anatomique atrial et des caractéristiques spectrales de la FA sur la FWA. Nous avons également analysé l’évolution de la fréquence dominante (dominant frequency, DF) de la FA au cours de l’ablation par radiofréquence de la FA persistante pour identifier les zones atriales jouant un rôle dans le maintien de l’arythmie, et nous avons effectué des corrélations avec des mesures électrophysiologiques directement accessibles au rythmologue pendant l’intervention pour aider à définir les cibles atriales appropriées. Nous avons inclus 29 patients ablatés de FA persistante par radiofréquence, avec isolation des veines pulmonaires et ablation du substrat atrial identifié par dispersion spatiotemporelle ou électrogrammes fragmentés complexes (>70% de l’enregistrement). La FWA était mesurée sur des ECG d’une minute par concaténation des intervalles TQ sur les dérivations DI, V1, V2 et V5 à l’état basal et immédiatement avant arrêt de la FA. La DF de la FA était mesurée sur les composantes indépendantes déduites des ECG d’une minute à l’état basal et après ablation de chaque zone atriale. Les drivers actifs (active drivers, AD) étaient différentiés des zones neutres (bystander zones, BZ) soit par une diminution significative de la DF (>10%), soit par arrêt de la FA. L’évolution de la FWA au cours de l’ablation a été comparée à celle de la DF. La FWA a été comparée à l’étendue des zones de bas voltage atriales, à la surface de tissu atrial sain, et à l’amplitude de l’onde P en rythme sinusal. La valeur prédictive de la FWA pour la récidive de la FA a été évaluée. Pour identifier les AD vs. BZ, plusieurs caractéristiques électrophysiologiques ont été évalués comme l’Average Complex Interval (ACI), permettant une mesure automatisée du cycle moyen entre deux activations locales endocardiques. Nous avons trouvé que la FWA restait stable au cours de l’ablation avec des valeurs comparables à l’état basal et avant arrêt de la FA, alors que la DF diminuait significativement. La FWA sur V5 était fortement corrélée à la surface de tissu atrial sain. La FWA démontrait une corrélation modérée à forte avec l’amplitude de l’onde P dans toutes les dérivations. Egalement, la FWA ne prédisait pas la récidive de FA durant le suivi. Sur les 159 zones atriales évaluées, l’ACI était plus court pour les AD que les BZ, et l’ACI moyen de toutes les zones de substrat était plus court chez les patients chez qui la radiofréquence échouait à réduire la FA. La récidive de la FA était associée avec plus de zones ayant un ACI similaire à l’ACI le plus court du patient. En analyse multivariée, un ACI 75 ms prédisait un arrêt de la FA durant la procédure. Ces résultats suggèrent que la FWA n’a pas de lien direct avec la complexité de la FA mais est surtout déterminée par la quantité de tissu atrial viable ; de ce fait, la FWA devrait uniquement être considérée comme un marqueur de pathologie du tissu atrial. Egalement, l’ACI aide à identifier les drivers de la FA, et est corrélé avec l’arrêt de la FA et la récidive de la FA durant le suivi.Atrial fibrillation (AF) is the most frequent arrhythmia, and is responsible for significant morbidity and mortality. Its interventional treatment requires electrical isolation of the pulmonary veins, and usually additional ablation of specific atrial zones is performed in the setting of persistent AF. Persistent AF ablation based on intracardiac electrograms analysis is complex, and appropriate identification of atrial substrate is critical. Several signal parameters have been used for non-invasively characterizing AF complexity, and are linked to prognosis after treatment. Among them, the Fibrillatory Wave Amplitude (FWA) has been described as a non-invasive marker AF complexity, which seems to predict catheter ablation outcome. However, actual determinants of FWA remain incompletely understood. In this work, we sought to assess the respective implications of anatomical atrial substrate and AF spectral characteristics for FWA. We also analyzed the evolution of AF dominant frequency (DF) during radiofrequency ablation of persistent AF for identifying atrial zones playing a role in AF maintenance, and we performed correlations with readily accessible electrophysiological measures for helping the electrophysiologist in targeting appropriate substrate zones. We included 29 Persistent AF patients undergoing radiofrequency catheter ablation by pulmonary vein isolation and ablation of atrial substrate identified by Spatiotemporal Dispersion or Complex Fractionated Atrial Electrograms (>70% of recording). FWA was measured on 1-minute ECG by TQ concatenation in Lead I, V1, V2 and V5 at baseline and immediately before AF termination. AF DF was measured by Independent Component Analysis on 1-minute 12-Leads ECGs at baseline and after ablation of each atrial zone. Active drivers (AD) were differentiated from bystander zones (BZ) either by a significant decrease in DF (>10%), or by AF termination. FWA evolution during ablation was compared to that of AF DF. FWA was compared to the extent of endocardial low-voltage areas, to the surface of healthy left atrial tissue, and to P-wave amplitude in sinus rhythm. Predictive value of FWA for AF recurrence during follow-up was assessed. For predicting AD vs. BZ, several electrophysiological characteristics were assessed, such as the Average Complex Interval (ACI) which allows automated measurement of the mean local endocardial activation cycle. We found that FWA remained stable along ablation procedure with comparable values at baseline and before AF termination, whereas DF significantly decreased. FWA in V5 was strongly correlated with the surface of healthy left atrial tissue. FWA showed moderate to strong correlation to P-wave amplitude in all leads. Also, FWA did not predict AF recurrence during the follow-up. Over the 159 analyzed atrial areas, ACI was shorter in AD than BZ, and mean ACI of all substrate zones was shorter in patients for whom radiofrequency failed to terminate AF. AF recurrence was associated with more ACI zones with identical shortest value. In multivariate analysis, ACI75 ms predicted AF termination. These findings suggest that FWA is unrelated to AF complexity but is mainly determined by the amount of viable atrial myocytes; therefore, FWA should only be referred as a marker of atrial tissue pathology. Also, ACI helps in identifying AF drivers, and is correlated with AF termination and AF recurrence during follow-up

La force de contact et de l'intégrale force-temps dans les ablations atriales par radiofréquence prédisent la transmuralité des lésions à travers l'analyse des électrogrammes endocavitaires

NICE-BU Médecine Odontologie (060882102) / SudocSudocFranceF

211: Left atrial flutter occurring after atrial fibrillation ablation: ablation using remote magnetic navigation versus manual technique

IntroductionLimited data exist on the efficacy and safety of remote magnetic navigation (RMN) ablation of iatrogenic left atrial flutter (LAF) occurring after atrial fibrillation (AF) ablation.MethodsLAF ablation procedures (proc) were reviewed. Patients (pts) were divided into 2 groups (gr): RMN gr if proc were performed remotely using the Niobe system (Sterotaxis) and conventional gr (CON) if proc were performed with manually driven catheters. Open-irrigated 3.5mm-tip catheters were used in all pts. Activation LA maps were realized in all pts using Carto or EnSite). Acute (defined as sinus rhythm- SR- resumption during ablation) and long-term (defined as SR maintenance) proc success, proc duration, fluoroscopy and radiofrequency (RF) times, and the mechanism of arrhythmias were studied.ResultsIn 46 pts (38 males, 60.8±10.19 y) 57 LAF ablation proc were performed. Age and LA size were similar. Activation maps showed: a unique macro-reentrant circuit 46%, multiples successive macro-reentrant circuits 26%, focal pulmonary vein tachycardia 9%, micro-reentrant circuit 19%. Results are showed in the table. Complications occurred in 3 proc: 1 in the RMN gr (groin hematoma) and 2 in the CON gr (1 transient ischemic attack and 1 cardiac perforation with tamponade). Perimitral flutter that occurred at any stage of the proc was associated with significantly higher rate of acute failure (persistent perimitral flutter at the end of the proc, both gr): 44% vs 12% for other types of flutter, p=0.02.RMN (n=25)CON (n=32)pAcute success80%78%0.86Proc/pt1.2±0.51.2±0.80.74Long-term success (follow-up 12.5±11.3 months)81%66%0.44Fluoroscopy748±377 s1086±772 s0.05Proc time236±68 min201±72 min0.06RF time1291±880 s1181±897 s0.70ConclusionAs compared to manual proc, RMN guided ablation for LAF after AF ablation provides comparable acute and long-term success rate but is potentially safer

Atrial fibrillation ablation in a single atrium with inferior vena cava interruption

Abstract Common atrium (CA), also called three‐chambered heart, is one of the rare congenital anomalies, defined by a complete absence of the atrial septum, eventually associated with malformation of the atrioventricular (AV) valves. We report the case of a 57‐year‐old woman with CA complicated with Eisenmenger syndrome and inferior vena cava interruption, who suffered from symptomatic persistent atrial fibrillation (AF). She underwent an initial successful pulmonary vein isolation procedure. A repeat procedure for perivalvular atrial flutter was complicated with inadvertent complete AV block, due to unusual AV node location in this challenging anatomy