Left atrial flutter after radiofrequency catheter ablation of focal atrial fibrillation

We report an arrhythmic complication in two patients in whom a procedure directed at isolating one or two pulmonary veins had been performed. The complication was related to pulmonary vein disconnection scars after ablation. Both patients developed new clinical tachycardia (atypical atrial flutter) secondary to a reentrant phenomena in the vicinity of a previously ablated pulmonary vein.     

Role of the vein of marshall in atrial fibrillation recurrences after catheter ablation: therapeutic effect of ethanol infusion

Vein of Marshall Ethanol in Recurrent AF. Introduction: Atrial fibrillation (AF) or flutter can recur after pulmonary vein (PV) antral isolation (PVAI). The vein of Marshall (VOM) has been linked to the genesis of AF. We hypothesized that the VOM may play a role in AF recurrences and that VOM ethanol infusion may have therapeutic value in this setting. Methods and Results: Sixty-one patients with recurrent AF or flutter after PVAI were studied. The VOM was successfully cannulated in 54; VOM and PV electrograms were recorded, and differential PV-VOM pacing was performed. VOM signals were present in all patients; however, VOM triggers of AF could not be demonstrated. VOM tachycardia was present in 1 patient. Left inferior (LIPV) and left superior (LSPV) reconnection was present in 32 and 30 patients, respectively. Differential pacing in VOM and LIPV showed VOM-mediated LIPV reconnection in 5/32 patients. In others, VOM and PV connected indirectly via left atrial tissues. Up to four 1 cc infusions of 98% ethanol were delivered in the VOM. Regardless of the reconnection pattern, ethanol infusion eliminated LIPV and LSPV reconnection in 23/32 and 13/30 patients, respectively. Ethanol terminated VOM and LIPV tachycardias in 2 patients. There were no acute procedural complications. Conclusions: VOM signals are consistently present in recurrent AF. VOM may rarely play a role in PV reconnection. However, VOM ethanol infusion can be useful in patients with recurrent AF after PVAI, assisting in achieving redisconnection of reconnected left PVs.     

峡部依赖性心房扑动对心房颤动发作的影响

目的观察导管射频消融治疗峡部依赖性心房扑动(房扑)对心房颤动(房颤)发作的影响,进一步探讨房扑和房颤的关系。方法86例房扑患者,其体表心电图均提示典型房扑,男性54例、女性32例,年龄50.0±15.6(11～74)岁,病程5.6±6.4(0.1～30)年。将所有患者分成A、B两组,A组为房扑合并房颤患者,共25例;B组为不合并房颤患者,共61例;其中A组同时合并房室结折返性心动过速(AVNRT)3例,房室折返性心动过速(AVRT)4例,阵发性房性心动过速(PAT)10例;B组合并房室结折返性心动过速5例,房室折返性心动过速7例。对峡部依赖性房扑者,线性消融下腔静脉—三尖瓣环峡部致双向传导阻滞;房室折返性心动过速者行旁道消融术;房室结折返性心动过速者行慢径改良术,阵发性房速术中持续或可诱发,予以射频消融。平均随访27.1±14.1(6～63)月。结果A组25例患者中,术后68%(17/25)患者不再发作房颤;其余8例仍有房颤发作,其中1例为术前同时合并房室折返性心动过速,5例为合并阵发性房速。61例术前不合并房颤者,术后随访中有16.4%(10/61)新发房颤。86例患者中,6例因病态窦房结综合征行起搏器植入术,随访未诉心悸、胸闷,心电图为窦性心律与起搏心律交替出现。结论房扑可能与房颤具有共同的发生基质,也可以是房颤的触发因素,成功消融房扑后可以阻止房颤的发生。但房颤发生机制多样,消融峡部依赖性房扑,仍会发生房颤,术前合并房颤或房速者是最强的预测因子。     

Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation

This report describes a fatal case of left atrial-esophageal fistula occurring in a 72-year-old man after a radiofrequency catheter ablation of paroxysmal atrial fibrillation. Catheter ablation was performed around the pulmonary vein using an 8-mm-tip electrode (60 W or 55 degrees C) guided by a 25-mm circular catheter. On day 22 of follow-up, the patient presented with seizures followed by hematemesis due to left atrial-esophageal fistula. His clinical condition deteriorated, and he died of speticemia. Thus, left atrial-esophageal fistula is a sever complication of radiofrequency catheter ablation of the left atrial posterior wall.     

心房颤动左心房内线性消融后的非典型性心房扑动

目的　左心房线性消融治疗心房颤动 (AF)后的非典型性心房扑动 (AAF)值得引起重视。方法　 2 4例患者 (男性 2 0例 ,女性 4例 ) ,年龄平均 5 1 2± 10 9(2 2～ 6 7)岁 ,左心房内径 33 9± 5 5(2 2～ 4 2 )mm。其中阵发性AF(PAF) 19例 ,持续性AF 5例。均在非接触式标测的指导下在左、右肺静脉口外进行环行消融 ,并在顶部肺静脉口间及二尖瓣环峡部行线性消融。在AF终止后经冠状静脉窦进行程序刺激以检验效果并观察是否存在AAF。结果　全部 19例PAF患者中 ,18例的左心房内线性消融获即时成功 ,1例经体外电转复 ;5例持续性AF者有 4例在消融后电转复成功 ,1例未能转复。共有 5例诱发出左心房AAF ,1例被超速抑制 ,2例在左心房顶部左、右肺静脉口之间 ,2例在二尖瓣峡部消融终止了AAF。在随访 7 5± 7(1～ 30 )月 ,除在肺静脉口间消融成功的 2例之外 ,其余 3例AAF均复发 ,2例服抗心律失常药物控制可维持窦性心律为主 ,1例因为 4∶1AV传导无症状而不愿接受治疗。结论　在左心房内进行线性消融治疗房颤存在引发非典型性房扑的可能 ,所采用的消融导管类型可能对其也存在一定影响 ,值得重视     

Predictors of recurrence following catheter ablation of atrial fibrillation using an irrigated-tip ablation catheter

INTRODUCTION: The aims of this study were to identify predictors of recurrence after catheter ablation of atrial fibrillation (AF) and to report the safety and efficacy of catheter ablation of AF using an irrigated-tip ablation catheter. METHODS AND RESULTS: Seventy-five consecutive patients (51 men [68%]; age 54 +/- 13 years) with symptomatic drug-refractory paroxysmal (42 patients), persistent (21 patients), or permanent (12 patients) AF underwent catheter ablation of AF using an irrigated-tip ablation catheter and a standard ablation strategy, which involved electrical isolation of all pulmonary veins (PVs) and creation of a cavotricuspid linear lesion. At 10.5 +/- 7.5 months of follow-up following a single (n = 75) or redo ablation procedure (n = 11), 39 (52%) of the 75 patients were free of AF, 10 were improved (13%), and 26 had experienced no benefit from the ablation procedure (35%). Seventy-six percent of patients with paroxysmal AF were free from recurrent AF. The most significant complications were two episodes of pericardial tamponade, mitral valve injury in one patient, two strokes, and complete but asymptomatic PV stenosis in one patient. Cox proportional hazards multivariate regression analysis identified the presence of persistent AF, permanent AF, and age >50 years prior to the ablation are the only independent predictors of AF recurrence after the first PV isolation procedure. CONCLUSION: Catheter ablation of AF using a strategy involving isolation of all PVs and creation of a linear lesion in the cavotricuspid isthmus using cooled radiofrequency energy is associated with moderate efficacy and an important risk for complications. The best results of this procedure are achieved in the subset of patients who are younger than 50 years and have only paroxysmal AF.     

Increased resting heart rate following radiofrequency catheter ablation for atrial fibrillation

AIM: Sinus tachycardia has been observed following radiofrequency(RF) catheter ablation for various kinds of supraventriculartachycardia. This study is aimed at determining the occurrenceof changes in sinus-rhythm heart rate (HR) after pulmonary vein(PV) isolation in patients with paroxysmal/persistent atrialfibrillation (AF), prospectively. METHODS: Patients with a history of AF underwent segmental or circumferentialisolation of the PVs. A total of 62 consecutive patients, meanage 55 10, was included. Clinical evaluation was performedbefore and one, three, six, nine, and 12 months following theprocedure. RESULTS: Following PV isolation, the mean HR significantly increasedfrom 58 10 bpm at baseline to 67 12 bpm at one month, 71 13 bpm at three months, 69 12 bpm at six months, 69 13at nine months, and 70 13 at 12 months follow-up. The ablationsuccess significantly correlated with the increase in HR atone month follow-up. In three patients the mean HR increased> 25 bpm resulting in symptoms necessitating therapy withrate-controlling drugs. CONCLUSION: PV isolation in patients with AF may result in increased HR,which positively correlated with the ablation success. Thischange does not seem to resolve spontaneously after a follow-upof 12 months. Approximately 5% of patients may develop symptomsdue to an increased HR, necessitating treatment with rate-controllingdrugs.     

The role of posterior wall isolation in catheter ablation of persistent atrial fibrillation

The left atrial posterior wall has many embryologic, anatomic, and electrophysiologic characteristics, that are important for the initiation and maintenance of persistent atrial fibrillation. The left atrial posterior wall is a potential target for ablation in patients with persistent atrial fibrillation, a population in whom pulmonary vein isolation alone has resulted in unsatisfactory recurrence rates. Published clinical studies report conflicting results on the safety and efficacy of posterior wall isolation. Emerging technologies including optimized use of radiofrequency ablation, pulse field ablation, and combined endocardial/epicardial ablation may optimize approaches to posterior wall isolation and reduce the risk of injury to nearby structures such as the esophagus. Critical evaluation of future and ongoing clinical studies of posterior wall isolation requires careful scrutiny of many characteristics, including intraprocedural definition of posterior wall isolation, concomitant extrapulmonary vein ablation, and study endpoints.     

三尖瓣峡部消融对心房颤动导管消融术后复发的影响

目的:评估三尖瓣峡部消融对伴有典型心房扑动(房扑)和不伴典型房扑发作的心房颤动(房颤)患者术后复发的影响.方法:连续入选房颤射频消融治疗患者113例,根据有无典型房扑分为三尖瓣峡部消融组(CTI组)和未行三尖瓣峡部消融组(Non-CTI组),比较临床特征及手术特点,并随访术后典型房扑和房颤发生率.结果:Non-CTI组左房内径更大,持续性和永久性房颤的比例、左房线性消融的比例更高.而CTI组射频消融时间较Non-CTI组更长.术后典型房扑和房颤发生率2组无显著区别.结论:无典型房扑发作的房颤患者,不行三尖瓣峡部消融,不会升高术后典型房扑发生率和房颤复发率,同时射频消融时间缩短.     

Incidence and predictors of pulmonary vein stenosis following catheter ablation of atrial fibrillation using the anatomic pulmonary vein ablation approach: results from paired magnetic resonance imaging

INTRODUCTION: There are currently no studies systematically evaluating pulmonary vein (PV) stenosis following catheter ablation of atrial fibrillation (AF) using the anatomic PV ablation approach. METHODS AND RESULTS: Forty-one patients with AF underwent anatomic PV ablation under the guidance of a three-dimensional electroanatomic mapping system. Gadolinium-enhanced magnetic resonance (MR) imaging was performed in all patients prior to and 8-10 weeks after ablation procedures for screening of PV stenosis. A PV stenosis was defined as a detectable (> or =3 mm) narrowing in PV diameter. The severity of stenosis was categorized as mild (<50% stenosis), moderate (50-70%), or severe (>70%). A total 157 PVs were analyzed. A detectable PV narrowing was observed in 60 of 157 PVs (38%). The severity of stenosis was mild in 54 PVs (34%), moderate in five PVs (3.2%), and severe in one PV (0.6%). All mild PV stenoses displayed a concentric pattern. Moderate or severe PV stenosis was only observed in patients with an individual encircling lesion set. Multivariable analysis identified individual encircling lesion set and larger PV size as the independent predictors of detectable PV narrowing. All patients with PV stenosis were asymptomatic and none required treatment. CONCLUSIONS: The results of this study demonstrate that detectable PV narrowing occurs in 38% of PVs following anatomic PV ablation. Moderate or severe PV stenosis occurs in 3.8% of PVs. The high incidence of mild stenosis likely reflects reverse remodeling rather than pathological PV stenosis. The probability of moderate or severe PV stenosis appears to be related to creation of individual encircling rather than encircling in pairs lesion.     

Double multielectrode mapping catheters facilitate radiofrequency catheter ablation of focal atrial fibrillation originating from pulmonary veins

INTRODUCTION: Several reports have demonstrated that focal atrial fibrillation (AF) may arise from pulmonary veins (PVs). The purpose of this study was to investigate the safety and efficacy of using double multielectrode mapping catheters in ablation of focal AF. METHODS AND RESULTS: Forty-two patients (30 men, 12 women, age 65+/-14 years) with frequent attacks of paroxysmal AF were referred for catheter ablation. After atrial transseptal procedure, two long sheaths were put into the left atrium. Two decapolar catheters were put into the right superior PV (RSPV) and left superior PV (LSPV), or inferior PVs if necessary, guided by pulmonary venography. All the patients had spontaneous initiation of AF either during baseline (2 patients), after isoproterenol infusion (8 patients) or high-dose adenosine (2 patients), after short duration burst pacing under isoproterenol (14 patients), or after cardioversion of pacing-induced AF (16 patients). The trigger points of AF were from the LSPV (12 patients), RSPV (8 patients), and both superior PVs (19 patients). The trigger points from PVs (total 61 points) were 18 (30%) in the ostium of PVs and 43 inside the PVs (9 to 40 mm). After 6+/-3 applications of radiofrequency energy, 57 of 61 triggers were completely eliminated, and the other 4 triggers were partially eliminated. During a follow-up period of 8+/-2 months, 37 patients (88%) were free of symptomatic AF without any antiarrhythmic drugs. Twenty patients received a transesophageal echocardiogram, and 19 showed small atrial septal defects (2.8+/-1.2 mm) with trivial shunt. Fifteen defects closed spontaneously 1 month later. CONCLUSION: The technique using double multielectrode mapping catheters is a relatively safe and highly effective method for mapping and ablation of focal AF originating from PVs.     

Mechanical esophageal displacement during catheter ablation for atrial fibrillation

Esophageal Deviation in AF Ablation. Objective: To determine the feasibility and safety of esophageal displacement during atrial fibrillation (AF) ablation, to prevent thermal injury. Background: Patients undergoing AF ablation are at risk of esophageal thermal injury, which ranges from superficial ulceration, to gastroparesis, to the rare but catastrophic atrioesophageal fistula. A common approach to avoid damage is luminal esophageal temperature (LET) monitoring; however, (1) temperature rises mandate interruptions in energy delivery that interrupt workflow and potentially decrease procedural efficacy, and (2) esophageal fistulas have been reported even with LET monitoring. Methods: A cohort of 20 consecutive patients undergoing radiofrequency (RF) (16 patients) or laser balloon (4 patients) ablation of AF under general anesthesia. After barium instillation, the esophagus was deviated using an endotracheal stylet placed within a thoracic chest tube. LET monitoring was used during catheter ablation. Upper GI endoscopy was performed prior to discharge. Results: At the pulmonary vein level, leftward deviation measured 2.8 ± 1.6 cm (range: 0.4–5.7) and rightward deviation 2.8 ± 1.8 cm (range: 0.5–4.9). The temperature rose to >38.5 °C in 3/20 (15%) patients. In these 3 patients, there was an average of 2 applications/patient that recorded temperatures >38.5 °C. No patient had a temperature rise > 40 °C. Endoscopy revealed no esophageal ulceration from thermal injury in 18/19 (95%) patients; the sole patient with a thermally mediated ulceration had an unusual esophageal diverticulum fully across the posterior left atrium. Twelve patients (63%) exhibited trauma related to instrumentation with no clinical sequelae. Conclusions: Mechanical esophageal deviation is feasible and allows for uninterrupted energy delivery along the posterior wall during catheter ablation of AF. J Cardiovasc Electrophysiol, Vol. 23, pp. 147‐154, February 2012)