Comparison between superior vena cava ablation in addition to pulmonary vein isolation and standard pulmonary vein isolation in patients with paroxysmal atrial fibrillation with the cryoballoon technique

Background

Paroxysmal atrial fibrillation (PAF) can be triggered by non-pulmonary vein foci, like the superior vena cava (SVC). The latter is correlated with improved result in terms of freedom from atrial tachycardias (ATs), when electrical isolation of this vessel utilizing radiofrequency energy (RF) is achieved.

Objectives

Evaluate the clinical impact, in patients with PAF, of the SVC isolation (SVCi) in addition to ordinary pulmonary vein isolation (PVI) by means of the second-generation cryoballoon (CB)

Methods

A total of 100 consecutive patients that underwent CB ablation for PAF were retrospectively selected. Fifty consecutive patients received PVI followed by SVCi by CB application, and the following 50 consecutive patients received standard PVI. All patients were followed 12 months.

Results

The mean time to SVCi was 36.7 ± 29.0 s and temperature at SVC isolation was ? 35 (? 18 to ? 40) °C. Real-time recording (RTR) during SVCi was observed in 42 (84.0%) patients. At the end of 12 months of follow-up, freedom from ATs was achieved in 36 (72%) patients in the PVI only group and in 45 (90%) patients of the SVC and PV isolation group (Fisher’s exact test p = 0.039, binary logistic regression: p = 0.027, OR = 0.28, 95%CI = 0.09–0.86). In survival analysis, SVC and PV isolation group was also associated with improved freedom from ATs (log-rank test: p = 0.017, Cox regression: p = 0.026, HR = 0.31, 95%CI = 0.11–0.87).

Conclusion

Superior vena cava isolation with the CB in addition to PVI might improve freedom from ATs if compared to PVI alone at 1-year follow-up.

     

Renal sympathetic denervation in addition to pulmonary vein isolation reduces the recurrence rate of atrial fibrillation: an updated meta-analysis of randomized control trials

Background/purpose

Atrial fibrillation (AF) is the most common arrhythmia worldwide. The sympathetic nervous system plays an important role in initiation and maintenance of AF. Recent studies have shown that renal sympathetic denervation (RSD) reduced AF recurrences after conventional pulmonary vein isolation (PVI). Studies that have evaluated the role of RSD as an adjuvant to PVI have included different patient populations, ablation strategies, and follow-up approaches. We performed a meta-analysis to assess the potential incremental impact of RSD to PVI.

Methods

We searched the databases of MEDLINE and EMBASE from inception to January 2020. Included studies were randomized controlled trials (RCTs) that compared the recurrence rates of AF in patients who underwent PVI and RSD versus PVI alone. Data from each study were combined using the random effects model to calculate odds ratios (OR) and 95% confidence intervals (CIs).

Results

Three RCTs consisted of four different studies during 2014–2020 involving 451 AF patients (223 patients underwent PVI alone and 228 patients underwent PVI with RSD) were included in the meta-analysis. Compared with PVI alone, the PVI with RSD group had a significantly lower risk of AF recurrence (pooled OR?=?0.63, 95%CI 0.50–0.80, p?<?0.001, I² =?0.0%). There was no publication bias observed in funnel plot as well as no small-study effect observed in Egger’s test.

Conclusions

Our systematic review and meta-analysis demonstrated a significant reduction of AF recurrence in select hypertensive patients who underwent RSD in addition to PVI compared with PVI alone. Larger studies are needed to validate the benefits of this approach in other AF populations and across different ablation strategies.

     

Pulmonary vein isolation using second-generation single-shot devices: not all the same?

Introduction

Single-shot devices have been developed to simplify pulmonary vein isolation (PVI). Randomized studies of the second-generation cryoballoon (CB 2nd) demonstrated excellent results. There are limited data comparing results of circular pulmonary vein ablation catheter (PVAC) with conventional RF ablation or CB for PVI.

Objective

Using a sequential registry cohort and a prospective randomized study, we aimed to compare the acute and long-term results of CB 2nd and PVAC Gold.

Methods

In the registry, consecutive patients with paroxysmal atrial fibrillation (AF) undergoing their first PVI were included. The preferred method used was PVAC Gold in 2014 and CB 2nd in 2015. Subsequently, a randomized study (PVAC vs. CB 2nd) was performed. Ablation success was measured as freedom of AF or atrial tachycardias (AT) off antiarrhythmic drugs.

Results

In the registry cohort, PVAC Gold was used in 60 patients and CB 2nd in 56 patients (age 66?±?11 years, 52% male, LAD 43?±?6). In the randomized study, 20 patients were treated with PVAC Gold and 22 with CB 2nd (age 67?±?9; 43% men, LAD 40?±?7 mm). During a mean follow up of 13.2?±?3.6 months, success was 54% in PVAC Gold patients and 81% in CB 2nd cases (p?=?0.001). In the randomized study 12 months success was 50% versus 86%, p?<?0.05. Complications occurred rare in both groups.

Conclusions

Our registry data and the randomized study both suggest superiority of PVI using CB 2nd as compared with PVI using PVAC Gold.

     

Operator learning curve and clinical outcomes of zero fluoroscopy catheter ablation of atrial fibrillation,supraventricular tachycardia,and ventricular arrhythmias

Purpose

To investigate the learning curve for atrial fibrillation (AF), supraventricular tachycardia (SVT), and premature ventricular contraction (PVC) radiofrequency ablation (RFA) using zero fluoroscopy.

Methods

This is a retrospective, single-center study of 167 patients undergoing ablation between 2016 and 2019. Minimal fluoroscopy approach was initiated after the first 20 cases of PVI and SVT RFA. Procedures were divided consecutively into increments of 10 cases to determine operator learning curve.

Results

A total of 64 (38%) had SVT ablations, 26 (16%) had PVC ablations, and 77 (46%) had AF and underwent PVI. For SVT RFA, fluoroscopy time improved from 4.1?±?3.5 min during the first 10 cases to 0.8?±?1.2 min after 50 cases (p?=?0.0001). Sixty-two out of 64 (97%) of cases were successful. In PVC RFA, fluoroscopy time was 7.7?±?5.5 min for the first 5, 2.3?±?3.4 min after 15, and 0 min after 20 cases (p?=?0.0008). Twenty-four out of 26 (92%) of cases were acutely successful with recurrence in 2/26 (8%) of patients over 9?±?9 months. In PVI, fluoroscopy time was 9.9?±?3.3 min over the first 20 cases, 2.6?±?2.3 min after 40 cases, and 0.1 min after 50 cases (p?<?0.0001). PVI procedure time was 170?±?34 min after 60 cases from 235?±?41 min initially (p 0.001). Six out of 77 (8%) had AF recurrence at 12 months.

Conclusions

Zero fluoroscopy ablation for AF, SVT, and PVC can be safely achieved without increasing procedure time. The steepest learning curve occurs over the first 20, 15, and 40 cases for SVT, PVC, and PVI ablation respectively.

     

Catheter Ablation of Low-Voltage Areas for Persistent Atrial Fibrillation: Procedural Outcomes Using High-Density Voltage Mapping

BackgroundSeveral approaches have been proposed to address the challenge of catheter ablation of persistent atrial fibrillation (AF). However, the optimal ablation strategy is unknown. We sought to evaluate the efficacy of pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation using contemporary high-density mapping to identify LVA in patients with persistent AF.MethodsConsecutive patients accepted for AF catheter ablation were studied. High-density bipolar voltage mapping data were acquired in sinus rhythm using multipolar catheters to detect LVA (defined as bipolar voltage < 0.5 mV). Semiautomated impedance-based software was used to ensure catheter contact during data collection. Patients underwent PVI + LVA ablation (if LVA present).ResultsA total of 145 patients were studied; 95 patients undergoing PVI + LVA ablation were compared with 50 controls treated with PVI only. Average age was 61 ± 10 years, and 80% were male. Baseline characteristics were comparable. Freedom from atrial tachycardia/AF at 18 months was 72% after PVI + LVA ablation vs 58% in controls (P = 0.022). Median procedure duration (273 [240, 342] vs 305 [262, 360] minutes; P = 0.019) and radiofrequency delivery (50 [43, 63] vs 55 [35, 68] minutes; P = 0.39) were longer in the PVI + LVA ablation group. Multivariable analysis showed that the ablation strategy (PVI + LVA) was the only independent predictor of freedom from atrial tachycardia/AF (hazard ratio, 0.53; 95% confidence interval, 0.29-0.96; P = 0.036). There were no adverse safety outcomes associated with LVA ablation.ConclusionsAn individualized strategy of high-density mapping to assess the atrial substrate followed by PVI combined with LVA ablation is associated with improved outcomes. Adequately powered randomized clinical trials are needed to determine the role of PVI + LVA ablation for persistent AF.     

CMR-Guided Approach to Localize and Ablate Gaps in Repeat AF Ablation Procedure

ObjectivesThe aim of this study was to test the feasibility and usefulness of a new delayed-enhancement cardiac magnetic resonance (DE-CMR)–guided approach to ablate gaps in redo procedures.BackgroundRecurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) may be related to gaps at the ablation lines. DE-CMR allows identification of radiofrequency lesions and gaps (CMR gaps).MethodsFifteen patients undergoing repeated AF ablations were included (prior procedure was PVI in all patients and roof-line ablation in 8 patients). Pre-procedure 3-dimensional (3D) DE-CMR was performed with a respiratory-navigated (free-breathing) and electrocardiographically gated inversion-recovery gradient-echo sequence (voxel size 1.25 × 1.25 × 2.5 mm). Endocardium and epicardium were manually segmented to create a 3D reconstruction (DE-CMR model). A pixel signal intensity map was projected on the DE-CMR model and color-coded (thresholds 40 ± 5% and 60 ± 5% of maximum intensity). The DE-CMR model was imported into the navigation system to guide the ablation of CMR gaps, with the operator blinded to electrical data. Fifteen conventional procedures were used as controls to compare procedural duration, radiofrequency, and fluoroscopy times.ResultsFifteen patients (56 pulmonary veins [PVs]; 57 ± 8 years of age; 9 with paroxysmal AF) were analyzed. In total, 67 CMR gaps were identified around PVs (mean 4.47 gaps/patient; median length 13.33 mm/gap) and 9 at roof line. All of the electrically reconnected PVs (87.5%) had CMR gaps. The site of electrical PV reconnection (assessed by circular mapping catheter) matched with a CMR gap in 79% of PVs. CMR-guided ablation led to reisolation of 95.6% of reconnected PVs (median radiofrequency time of 13.3 [interquartile range: 7.5 to 21.7] min/patient) and conduction block through the roof line in all patients (1.4 [interquartile range: 0.7 to 3.1] min/patient). Compared with controls, the CMR-guided approach shortened radiofrequency time (1,441 ± 915 s vs. 930 ± 662 s; p = 0.026) but not the procedural duration or fluoroscopy time.ConclusionsDE-CMR can successfully guide repeated PVI procedures by accurately identifying and localizing gaps and may reduce procedural duration and radiofrequency application time.     

Is radiofrequency energy a necessary and safe complement to cryotherapy for successful pulmonary vein isolation?

IntroductionPulmonary vein (PV) isolation is considered the cornerstone of atrial fibrillation (AF) catheter ablation. PV isolation (PVI) by means of cryotherapy has emerged as a promising technique due to both a low thrombogenicity and reduced risk of PV stenosis. The evaluation (need/efficiency/safety) of hybrid therapy (defined as the use of cryotherapy followed by that of radiofrequency energy in a given patient) is the aim of the present study.MethodsThirty-four consecutive patients (26 men, mean age: 56.7 ± 9.3 years) with symptomatic drug-refractory paroxysmal AF underwent PVI using a balloon-cryotherapy (BCT). A maximum of four cryotherapy applications was applied per PV and disconnection assessed thereafter using a circular LASSO® catheter. When necessary, PV disconnection was then performed using a 4 mm irrigated-tip catheter. All patients underwent CT-scan evaluation before discharge to detect acute PV stenosis.ResultsPVI could be achieved in all patients. Mean procedure duration was 230 ± 42 min and mean fluoroscopy time was 52 ± 13 min. Hybrid therapy was needed to achieve PVI in 26 of 34 (76%). With cryoablation solely, PVI was achieved in 90 of 136 (66%) targeted veins, efficacy being higher in superior as compared to inferior PVs (87% vs. 46%, p < 0.001). Besides one patient with permanent right phrenic nerve injury, no other procedure-related complications were observed. After a mean follow-up period of 8 ± 3 months, 28 patients (82%) did not experience AF recurrence (including six patients on antiarrhythmic drugs).ConclusionsOur study suggests that hybrid ablation therapy is necessary in most patients to achieve PV disconnection after a maximum of four blinded applications of balloon-cryotherapy (especially in inferior PVs), with a significant short-term success rate.     

Efficacy of extended antrum ablation based on substrate mapping plus pulmonary vein isolation in the treatment of atrial fibrillation

Introduction and objectivesPulmonary vein isolation (PVI) technique has become the cornerstone of atrial fibrillation (AF) catheter ablation. The objective of this study was to assess the efficacy and safety of extended antrum ablation based on electrophysiological substrate mapping plus PVI in AF patients who underwent cryoballoon ablation.MethodsIn this observational study, a total of 121 paroxysmal AF patients and 80 persistent AF patients who did not achieve the procedure endpoint after cryoballoon ablation received extra extended antrum ablation (EAA) based on electrophysiological substrate mapping via radiofrequency ablation (EAA group). As a control group (PVI group), among paroxysmal AF and persistent AF patients, we conducted a propensity score-matched cohort, in whom only PVI was completed.ResultsThe average follow-up time was 15.27±7.34 months. Compared with PVI group, paroxysmal AF patients in the EAA group had a significantly higher rate of AF-free survival (90.1% vs. 80.2%, p=0.027) and AF, atrial flutter, or atrial tachycardia (AFLAT) -free rate survival (89.3% vs. 79.3%, p=0.031). Persistent AF patients in the EAA group also had a significantly higher rate of AF-free survival (90.0% vs. 75.0%, p=0.016) and AFLAT-free survival (88.8% vs. 75.0%, p=0.029) than PVI group. Complication rates did not significantly differ between both groups, in either paroxysmal AF or persistent AF patients.ConclusionOur findings demonstrate that extra extended antrum ablation based on electrophysiological substrate mapping is effective and safe. Moreover, the strategy can improve the outcome of AF cryoablation.     

Clinical Utility of Central Venous Saturation for the Calculation of Cardiac Index in Cardiac Patients

BackgroundMixed venous saturation (MVS) obtained from the distal pulmonary artery (PA) during Swan-Ganz catheterization is the criterion standard for calculating cardiac output (CO) and cardiac index (CI) with the use of the Fick method. We think that calculating CI with the use of central venous saturation (CVS) instead of PA-MVS is both feasible and accurate. Earlier studies were small, enrolled heterogeneous patient populations, and resulted in inconsistent findings.MethodsAll patients undergoing right heart catheterization from January 2011 to January 2012 in our catheterization lab with simultaneous measurements of MVS obtained from the distal PA and CVS obtained from the superior vena cava (SVC) or right atrium (RA) were included. Out of the 902 patients enrolled, we excluded patients (n = 50) who had known cardiac shunt or dialysis fistula, had duplicate medical records, or were septic. We calculated the CI with the use of the assumed Fick method using both MVS (criterion standard) and CVS (SVC or RA saturations) in the remaining 852 patients. We measured the correlation and the agreement between the 2 methods with the use of the Pearson correlation coefficient and Bland-Altman analysis.ResultsTotals of 112 patients with simultaneous PA and RA saturation measurements (group I) and 740 patients with simultaneous PA and SVC saturation measurements (group II) were included. We found an excellent linear correlation between SVC and PA saturation (r = 0.928) and between RA and PA saturation (r = 0.95). There was also an excellent correlation between CI calculated with the use of PA saturation and CI calculated with the use of SVC (r = 0.87) or RA (r = 0.93) saturation. The mean bias of CVS-derived CI compared with MVS-derived CI (criterion standard) was −0.1 (95% limits of agreement [LOA] −1 to +0.77) in the SVC group and −0.006 (LOA −0.68 to +0.69) in the RA group. Patients with low CI had stronger correlation and smaller bias between the 2 methods compared with those with normal or high CI. The presence of baseline hypoxemia, valvular heart disease, or acute coronary syndrome had no significant effect on the correlation or the bias between the 2 methods.ConclusionsIn cardiac patients, CVS can be used as a surrogate to true MVS in the calculation of CI. This method is readily available in patients who have central venous access, and may aid in early goal-directed treatment when cardiogenic shock is suspected.     

Conventional pulmonary vein isolation compared with the “box isolation” method: a randomized clinical trial

Purpose  

Esophageal injury is a potential complication with radiofrequency ablation in the posterior wall of the left atrium (LA). The “box isolation” method isolates the posterior LA wall including the pulmonary veins without ablation on the posterior LA wall. This study compares the acute and long-term efficacy of the box isolation method with conventional circumferential pulmonary vein isolation (PVI) for catheter ablation of AF.     

Acute Kidney Injury Following In-Patient Lower Extremity Vascular Intervention: From the National Cardiovascular Data Registry

ObjectivesThe authors analyzed data from the NCDR (National Cardiovascular Data Registry) PVI Registry and defined acute kidney injury (AKI) as increased creatinine of ≥0.3 mg/dl or 50%, or a new requirement for dialysis after PVI.BackgroundAKI is an important and potentially modifiable complication of peripheral vascular intervention (PVI). The incidence, predictors, and outcomes of AKI after PVI are incompletely characterized.MethodsA hierarchical logistic regression risk model using pre-procedural characteristics associated with AKI was developed, followed by bootstrap validation. The model was validated with data submitted after model creation. An integer scoring system was developed to predict AKI after PVI.ResultsAmong 10,006 procedures, the average age of patients was 69 years, 58% were male, and 52% had diabetes. AKI occurred in 737 (7.4%) and was associated with increased in-hospital mortality (7.1% vs. 0.7%). Reduced glomerular filtration rate, hypertension, diabetes, prior heart failure, critical or acute limb ischemia, and pre-procedural hemoglobin were independently associated with AKI. The model to predict AKI showed good discrimination (optimism corrected c-statistic = 0.68) and calibration (corrected slope = 0.97, intercept of ?0.07). The integer point system could be incorporated into a useful clinical tool because it discriminates risk for AKI with scores ≤4 and ≥12 corresponding to the lower and upper 20% of risk, respectively.ConclusionsAKI is not rare after PVI and is associated with in-hospital mortality. The NCDR PVI AKI risk model, including the integer scoring system, may prospectively estimate AKI risk and aid in deployment of strategies designed to reduce risk of AKI after PVI.     

Ablation of persistent atrial fibrillation based on high density voltage mapping and complex fractionated atrial electrograms: A randomized controlled trial

Introduction:Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) catheter ablation. However, a PVI alone has been considered insufficient for persistent AF. This study aimed to evaluate the efficacy of persistent AF ablation targeting complex fractionated atrial electrogram (CFAE) areas within low voltage zones identified by high-resolution mapping in addition to the PVI.Methods:We randomized 50 patients (mean age 58.4 ± 9.5 years old, 86.0% males) with persistent AF to a PVI + CFAE group and PVI only group in a 1:1 ratio. CFAE and voltage mapping was performed simultaneously using a Pentaray Catheter with the CARTO3 CONFIDENSE module (Biosense Webster, CA, USA). The PVI + CFAE group, in addition to the PVI, underwent ablation targeting low voltage areas (<0.5 mV during AF) containing CFAEs.Results:The mean persistent AF duration was 24.0 ± 23.1 months and mean left atrial dimension 4.9 ± 0.5 cm. In the PVI + CFAE group, AF converted to atrial tachycardia (AT) or sinus rhythm in 15 patients (60%) during the procedure. The PVI + CFAE group had a higher 1-year AF free survival (84.0% PVI + CFAE vs 44.0 PVI only, P = .006) without antiarrhythmic drugs. However, there was no difference in the AF/AT free survival (60.0% PVI + CFAE vs 40.0% PVI only, P = .329).Conclusion:Persistent AF ablation targeting CFAE areas within low voltage zones using high-density voltage mapping had a higher AF free survival than a PVI only. Although recurrence with AT was frequent in the PVI+CFAE group, the sinus rhythm maintenance rate after redo procedures was 76%.     

Pulmonary vein isolation for atrial fibrillation: Does ablation technique influence outcome?

BackgroundOver the last 20 years various techniques have been developed striving for safer and more durable pulmonary vein isolation (PVI). The three most commonly used tools are pulmonary vein ablation catheter (PVAC) and cryoballoon (‘single-shot’ techniques), and point-by-point (PBP) radiofrequency ablation using 3D electroanatomical mapping (EAM).ObjectiveEvaluate the safety and efficacy of the different techniques in an unselected population undergoing de-novo ablation for persistent or paroxysmal atrial fibrillation (AF) at Royal Papworth Hospital (RPH).MethodRetrospective, single-centre study of consecutive AF ablations at RPH between March 2017 and April 2018. Demographic, procedural and outcome data were analysed.ResultsOver the study period 329 first-time PVI procedures were performed. 37.4% were performed using PBP, 39.8% using cryoballoon and 22.8% using PVAC. There was no significant difference in age or sex between different ablation technique groups. 238 procedures were performed for paroxysmal AF and 91 for persistent AF. A higher proportion of the persistent cases were performed using point-by-point techniques compared to paroxysmal cases (58.2% vs 29.0%, p < 0.05).Procedural times were significantly longer in the group undergoing PBP ablation compared to cryoballoon or PVAC. However, there was no statistically significant difference in 12-month freedom from symptomatic AF or procedural complications between the groups.ConclusionsPBP, PVAC and cryoballoon AF ablation all appeared equally efficacious in an unselected population, though PVAC and cryoballoon procedures were shorter. All procedures were associated with a low adverse event rate. Prospective examination is required to substantiate this finding.     

Radiological prediction of portal vein infiltration in patients with pancreatic ductal adenocarcinoma

BackgroundPancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy characterized by early loco-regional invasion. Portal vein resection (PVR) during pancreatoduodenectomy (PD) for PDAC is performed if tumor cell invasion to the venous wall (PVI) is suspected. The aim of this study is to evaluate radiological criteria for predicting PVR and PVI.MethodsPatients undergoing PD for PDAC were identified from a prospectively maintained database. On the basis of CT- and MRI-based imaging portal vein tumor contact (PV), stranding of the superior mesenteric artery (SMA) and any alterations of the superior mesenterico-portal vein (SMPV) were evaluated. The accuracy of PVI and PVR prediction based on the radiological parameters was calculated.Results143 patients were included in the study. 48 patients underwent PVR (34%), PVI was diagnosed in 23 patients (16%). Median overall survival was 22 months. Prediction of PVR (sensitivity 79%, negative predictive value 88%, p = 0.010) and PVI (sensitivity 95%, negative predictive value 99%, p = 0.002) was most accurate for any SMPV alterations as compared to the other radiological parameters. SMPV alterations qualified as an independent prognostic parameter (26.5 months vs. 33.5months, p = 0.034).ConclusionRadiological evaluation of any SMPV alterations is a simple preoperative method to accurately predict PVI. Assessing SMPV alterations may help to identify candidates for neoadjuvant therapy.     

Initial experience with fractionation mapping–guided ablation strategy in patients with long-standing persistent atrial fibrillation

Purpose

We aimed to define the role of extended pulmonary vein isolation (PVI), posterior wall isolation, and mitral isthmus lines to eliminate electrograms exhibiting fractionation pattern during stepwise ablation on acute atrial fibrillation (AF) termination rate in patients with long-standing persistent AF (LSPAF).

Methods

Twelve patients with LSPAF underwent ablation during AF. Using the fractionation mapping tool of the Ensite? (Abbott Medical, Chicago, USA) system, sites exhibiting discrete atrial complexes and consistent activation sequence were mapped. The areas with a fractionation score above 4 were accepted as potential drivers for AF. During stepwise ablation consisting of circumferential PVI, roof and floor lines for posterior wall isolation, and mitral isthmus lines, ablation lines were extended toward potential AF drivers on the fractionation map as much as possible until sinus was achieved by ablation.

Results

Fractionation-guided ablation caused acute AF termination in 8 of 12 patients. In 6 of 12 cases, AF returned to sinus rhythm during the extended ablation. In 2 patients, AF shifted to sinus after cavotricuspid isthmus ablation. Sinus was achieved by cardioversion in 3 of cases. Procedural failure was seen in one case with significant scar tissue. During a mean follow-up of 31.5?±?11 months, overall arrhythmia-free survival was 92% with 2 procedures.

Conclusions

This pilot study demonstrates that fractionation mapping–guided ablation may provide an adjunctive benefit in terms of acute AF termination in patients with LSPAF. These results should be confirmed by larger, randomized, comparison studies between linear ablation and extended ablation without elimination of electrograms (EGMs) with fractionation.

     

Effect of Paclitaxel-Coated Balloon Angioplasty on Side Branch Lesion and Cardiovascular Outcomes in Patients with De Novo True Coronary Bifurcation Lesions Undergoing Percutaneous Coronary Intervention

Purpose

To compare the effects of paclitaxal-coated balloon (PCB) versus conventional balloon (CB) on side branch (SB) lesion and cardiovascular outcomes in patients with de novo true bifurcation lesions.

Methods

In total, 219 patients with de novo true bifurcation lesions were enrolled and divided into PCB group (102 cases) and CB group (117 cases) according to angioplasty strategy in SB. Drug-eluting stent (DES) was implanted in main vessel (MV) for each subject. All subjects underwent a 12-month follow-up for late lumen loss (LLL), restenosis, and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI). MACEs included cardiac death, nonfatal myocardial infarction, and unstable angina requiring admission.

Results

There were no differences in diameter, minimum lumen diameter (MLD), and stenosis for bifurcation lesions between the two groups before and immediately after PCI (P?>?0.05). After 12-month follow-up, no differences occurred in MV-MLD and MV-LLL between the two groups (P?>?0.05); SB-MLD in PCB group was higher than that in CB group (1.97?±?0.36 mm vs. 1.80?±?0.43 mm, P?=?0.007); SB-LLL in PCB group was lower than that in CB group (0.11?±?0.18 mm vs. 0.19?±?0.25 mm, P?=?0.024). Multivariate COX analyses indicated that PCB group had lower MACE risk than CB group (HR?=?0.480, 95%CI 0.244–0.941, P?=?0.033).

Conclusion

PCB could decrease SB-LLL and MACE risk in patients with de novo true coronary bifurcation lesion 12 months after single-DES intervention.

     

Guideline-Directed Medical Therapy and Long-Term Mortality and Amputation Outcomes in Patients Undergoing Peripheral Vascular Interventions

BackgroundLack of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) may increase mortality and amputation risk.ObjectivesThe authors sought to study the association between GDMT and mortality/amputation and to examine GDMT variability among providers and health systems.MethodsWe performed an observational study using patients in the Vascular Quality Initiative registry undergoing PVI between 2017 and 2018. Two-year all-cause mortality and major amputation data were derived from Medicare claims data. Compliance with GDMT was defined as receiving a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker if hypertensive. Propensity 1:1 matching was applied for GDMT vs no GDMT and survival analyses were performed to compare outcomes between groups.ResultsOf 15,891 patients undergoing PVIs, 48.8% received GDMT and 6,120 patients in each group were matched. Median follow-up was 9.6 (IQR: 4.5-16.2) months for mortality and 8.4 (IQR: 3.5-15.4) for amputation. Mean age was 72.0 ± 9.9 years. Mortality risk was higher among patients who did not receive GDMT versus those on GDMT (31.2% vs 24.5%; HR: 1.37, 95% CI: 1.25-1.50; P < 0.001), as well as, risk of amputation (16.0% vs 13.2%; HR: 1.20; 95% CI: 1.08-1.35; P < 0.001). GDMT rates across sites and providers ranging from 0% to 100%, with lower performance translating into higher risk.ConclusionsAlmost one-half of the patients receiving PVI in this national quality registry were not on GDMT, and this was associated with increased risk of mortality and major amputation. Quality improvement efforts in vascular care should focus on GDMT in patients undergoing PVI.     

Negative pressure wound therapy in grade 1 and 2 diabetic foot ulcers: A randomized controlled study

Background and aimsFoot ulcers are one of the major causes of morbidity and mortality among diabetics in India. Early diagnosis and timely management is vital in preventing the progression of the disease which may require amputation. Conventional methods take a long time for healing. This study aims to compare negative pressure wound therapy (NPWT) and conventional saline dressings in diabetic foot ulcer (DFU) healing.MethodsThis prospective randomized study was conducted in 45 patients with grade 1 and 2 DFUs. 22 patients in group A received NPWT and 23 patients in group B received saline dressings. The formation of granulation tissue, reduction in ulcer size, duration of hospital stay and time for complete healing of wounds were assessed.ResultsThe formation of granulation tissue (91.14 vs 52.61%, p < 0.001) and reduction in ulcer size (40.78 vs 21.18%, p = 0.008) at 14 days was significantly more in group A. The duration of hospital stay (15.68 vs 29.00 days, p < 0.001) and time for 100% coverage of the wound with granulation tissue (14.82 ± 7.30 vs 44.57 ± 7.11 days, p < 0.001) was significantly less in group A. Complete healing of wounds at 3 months was observed in 20 patients (90.9%) in group A and 6 patients (26.1%) in group B (p = 0.006).ConclusionIn our study NPWT led to early reduction in ulcer size, more granulation tissue formation, shorter hospital stay and complete wound healing. In lower and middle income countries like India with high prevalence of DFUs, early recovery is a boon to the patients to resume their daily activities.     

Visual Assessment of Brain Magnetic Resonance Imaging Detects Injury to Cognitive Regulatory Sites in Patients With Heart Failure

BackgroundHeart failure (HF) patients exhibit depression and executive function impairments that contribute to HF mortality. Using specialized magnetic resonance imaging (MRI) analysis procedures, brain changes appear in areas regulating these functions (mammillary bodies, hippocampi, and frontal cortex). However, specialized MRI procedures are not part of standard clinical assessment for HF (which is usually a visual evaluation), and it is unclear whether visual MRI examination can detect changes in these structures.Methods and ResultsUsing brain MRI, we visually examined the mammillary bodies and frontal cortex for global and hippocampi for global and regional tissue changes in 17 HF and 50 control subjects. Significantly global changes emerged in the right mammillary body (HF 1.18 ± 1.13 vs control 0.52 ± 0.74; P = .024), right hippocampus (HF 1.53 ± 0.94 vs control 0.80 ± 0.86; P = .005), and left frontal cortex (HF 1.76 ± 1.03 vs control 1.24 ± 0.77; P = .034). Comparison of the visual method with specialized MRI techniques corroborates right hippocampal and left frontal cortical, but not mammillary body, tissue changes.ConclusionsVisual examination of brain MRI can detect damage in HF in areas regulating depression and executive function, including the right hippocampus and left frontal cortex. Visual MRI assessment in HF may facilitate evaluation of injury to these structures and the assessment of the impact of potential treatments for this damage.     

Impact of Radiofrequency Characteristics on Acute Pulmonary Vein Reconnection and Clinical Outcome After PVAC Ablation

Impact of Radiofrequency Characteristics . Objective: The objective was to study the impact of radiofrequency (RF) characteristics on acute pulmonary vein reconnection (PVR) and outcome after PVAC ablation. PVI with additional ablation of PVR (PVI + PVR) was compared to PVI‐only. Methods: In 40 consecutive patients, after PVAC‐guided PVI, adenosine and a 1‐hour waiting time were used to unmask and ablate acute PVR (PVI + PVR group). RF‐characteristics and 1‐year AF freedom were compared post hoc to 40 clinically matched patients undergoing PVI only (PVI‐only group). Custom‐made software was used to assess RF characteristics of the PVAC applications needed to obtain baseline PVI. Results: There was no difference in clinical characteristics or baseline RF‐profile between both groups. Acute PVR was observed and ablated in 38 of 160 veins (24%). AF‐freedom after PVI + PVR was higher than PVI (85% vs 65%, P < 0.05). Within the PVI group, comparing patients with and without AF‐recurrence, the percentage of PVAC applications with high T° (>48°) but low power (<3W) was higher (28 ± 18% vs 11 ± 11%, P < 0.0001). Within the PVI + PVR group, when comparing PVs with and without PVR, the percentage of low power/high T° PVAC applications was also higher (27 ± 13% vs 13 ± 15%, P < 0.0001). Conclusions: (1) After PVAC ablation, 24% of PVs exhibit acute reconnection. Additional ablation of reconnection improves clinical outcome. (2) Acute reconnection as well as clinical recurrence of AF are characterized by PVAC ablation with a considerable number of applications with high temperature but low power. (3) If PV isolation is obtained with low power applications, a consistent use of both adenosine and waiting time is required. (J Cardiovasc Electrophysiol, Vol. 24, pp. 290‐296, March 2013)