Pulmonary Vein Encirclement Using an Ablation Index Guided Point-by-Point Workflow:Cardiovascular Magnetic Resonance Assessment of Left Atrial Scar Formation

BackgroundA point-by-point workflow for pulmonary vein isolation (PVI) targeting pre-defined Ablation Index values (a composite of contact force, time and power) and minimising interlesion distance may optimise the creation of contiguous ablation lesions whilst minimising scar formation. We aimed to compare ablation scar formation in patients undergoing PVI using this workflow to patients undergoing a continuous catheter drag workflow.MethodsPost-ablation Cardiovascular Magnetic Resonance (CMR) imaging was performed in patients undergoing 1st time PVI using a parameter-guided point-by-point workflow (n=26). Total left atrial scar burden and the width and continuity of the pulmonary vein encirclement were determined on analysis of atrial late gadolinium enhancement sequences. Comparison was made with a cohort of patients (n=20) undergoing PVI using continuous drag lesions.ResultsMean post ablation scar burden and scar width were significantly lower in the point-by-point vs. the control group (6.66.8% vs. 9.65.0%, P=0.03 and 7.93.6mm vs. 10.72.3mm, P=0.003). More complete bilateral pulmonary vein encirclements were seen in the point-by-point group (P=0.038). All patients achieved acute pulmonary vein isolation.ConclusionPVI using a point-by-point workflow is feasible and results in a lower scar burden and scar width with more complete pulmonary vein encirclements than a conventional drag lesion approach. <br/

Nationwide prospective audit for the evaluation of appendicitis risk prediction models in adults: Right iliac fossa treatment (RIFT) - Turkey

Background: Appendicitis is the most prevalent surgical emergency. The negative appendicectomy rate and diagnostic uncertainty are important concerns. This study aimed to assess the effectiveness of current appendicitis risk prediction models in patients with acute right iliac fossa pain. Methods: A nationwide prospective observational study was conducted, including all consecutive adult patients who presented with right iliac fossa pain. Diagnostic, clinical and negative appendicectomy rate data were recorded. The Alvarado score, Appendicitis Inflammatory Response (AIR), Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Adult Appendicitis Score systems were calculated with collected data to classify patients into risk categories. Diagnostic value and categorization performance were evaluated, with use of risk category-based metrics including 'true positive rate' (percentage of appendicitis patients in the highest risk category), 'failure rate' (percentage of patients with appendicitis in the lowest risk category) and 'categorization resolution' (true positive rate/failure rate). Results: A total of 3358 patients from 84 centres were included. Female patients were less likely to undergo surgery than men (71.5% versus 82.5% respectively; relative risk 0.866, 95% c.i. 0.834 to 0.901, P 0.001); with a three-fold higher negative appendicectomy rate (11.3% versus 4.1% respectively; relative risk 2.744, 95% c.i. 2.047 to 3.677, P 0.001). Ultrasonography was utilized in 56.8% and computed tomography in 75.2% of all patients. The Adult Appendicitis Score had the best diagnostic performance for the whole population; however, only RIPASA was significant in men. All scoring systems were successful in females patients, but Adult Appendicitis Score had the highest area under the receiver operating characteristic curve value. The RIPASA and the Adult Appendicitis Score had the best categorization resolution values, complemented by their exceedingly low failure rates in both male and female patients. Alvarado and AIR had extremely high failure rates in men. Conclusion: The negative appendicectomy rate was low overall, but women had an almost three-fold higher negative appendicectomy rate despite lower likelihood to undergo surgery. The overuse of imaging tests, best exemplified by the 75.2% frequency of patients undergoing computed tomography, may lead to increased costs. Risk-scoring systems such as RIPASA and Adult Appendicitis Score appear to be superior to Alvarado and AIR. © 2024 The Author(s). Published by Oxford University Press on behalf of BJS Foundation Ltd.Tibbi Akademi