The superior vena cava as a site of ectopic foci in atrial fibrillation

Radiofrequency catheter ablation of ectopic foci that trigger atrial fibrillation has been established as a curative method for patients with symptomatic paroxysmal atrial fibrillation. Although the majority of these foci are located in and around the pulmonary veins, other less common locations have been identified. Recognition that foci can lie outside the pulmonary veins is important for ensuring therapeutic success. The most frequently reported foci of ectopic activity outside the pulmonary veins are in the superior vena cava and the posterior wall of the left atrium. Here we report our experience with the ablation of ectopic foci located in the superior vena cava in patients with symptomatic paroxysmal atrial fibrillation.     

Ablación con criobalón en pacientes jóvenes con fibrilación auricular paroxística aislada

Introduction and objectives

Long-term efficacy following cryoballoon ablation of lone paroxysmal atrial fibrillation remains unknown. We describe long-term follow-up results of the single cryoballoon ablation procedure.

Methods

Pulmonary vein isolation was performed in 103 patients (72 male; median age 52 years) with symptomatic lone paroxysmal atrial fibrillation. The end-point of this observational cohort study was first electrocardiogram-documented recurrence of arrhythmia (atrial fibrillation, atrial tachycardia, or atrial flutter) during the 5-year follow-up, in the absence of anti-arrhythmic treatment.

Results

Acute complete pulmonary vein isolation was achieved in 86% of the patients with a single cryoballoon. The 6-month, 1-year, and 5-year success rate after a single procedure was 94%, 91%, and 77%, respectively. Arrhythmia recurrence was observed in 24 cases at a median of 14.8 months [range, 8.0-16.8 months]. Thirteen symptomatic patients were well controlled on beta-blockers only. Seven symptomatic patients had anti-arrhythmic treatment (class IC in 5 patients; dronedarone in 2 patients) introduced during the blanking period. Two of them had early arrhythmia recurrence within the blanking period only; they were arrhythmia-free in further follow-up on dronedarone. The rate of complications was relatively low and included a 4.8% incidence of transient phrenic nerve palsy.

Conclusions

A single cryoballoon ablation procedure for lone paroxysmal atrial fibrillation resulted in high rates of acute, medium-term, and long-term efficacy. The rate of complications is relatively low and includes a 4.8% incidence of transient phrenic nerve palsy.Full English text available from:www.revespcardiol.org/en     

Radiofrequenz-Katheterablation von Vorhofflattern und Vorhofflimmern

Radiofrequency catheter ablation is now considered as a curative approach in patients with typical atrial flutter. Typical atrial flutter is due to a macrore-entrant circuit within the right atrium and it can be eliminated by a linear lesion in the isthmus between the tricuspid annulus and the vena cava inferior. The electrophysiological criterion of a bidirectional isthmus block has been shown to reduce the recurrence rate of atrial flutter after catheter ablation, thus achieving long-term cure of typical atrial flutter. Acute success rates of 85 to 90% and recurrence rates of 10 to 15% have been reported. The risk of paroxysmal atrial fibrillation continues to be clinically relevant in patients who underwent successful ablation of atrial flutter, in particular in patients with previously documented atrial fibrillation. The incidence of a new onset of atrial fibrillation after ablation of atrial flutter seems to be approximately 20%. Isthmus ablation has also been shown to be beneficial for the majority of patients with typical atrial flutter and atrial fibrillation: In addition to an elimination of typical atrial flutter the isthmus ablation apparently reduces the incidence of paroxysmal atrial fibrillation. At present, atrial fibrillation can only be treated by catheter ablation as a curative approach in the rare cases where an accessory pathway, an AV nodal re-entrant tachycardia, typical atrial flutter or an ectopic atrial tachycardia is the induction mechanism of the atrial fibrillation. The majority of patients with atrial fibrillation is apparently not amenable to a curative local ablation. While AV junction ablation and AV node modification can palliate some of the symptoms of atrial fibrillation by a control of ventricular rate, the arrhythmia persists with the loss of AV synchrony and continued risk of thromboembolism. The surgical MAZE procedure implies a compartimentation of the atria by surgical incisions resulting in areas to small to sustain the arrhythmia. Based on this procedure experimental and clinical studies are currently performed in order to develop catheter ablation cure of atrial fibrillation.     

Ablation of atrial fibrillation: where are we now?]

Atrial fibrillation is the commonest arrhythmia. Besides the risk of complications, a significant number of patients remain symptomatic despite the different anti-arrhythmic drugs currently available. The only curative treatment is by surgery or catheter ablation. Since 1994, several approaches have been developed based on two main concepts: modification of the arrhythmogenic substrate by linear lesion to prevent the perpetuation of the arrhythmia and ablation of the foci initiating the atrial fibrillation. The later approach is the most popular one at the moment because the concentration of foci at the site of the pulmonary veins makes it possible to isolate them relatively easily. The presence of atrial foci in some patients complicates matters and limits the success rate to 70%. Despite these limitations and with an acceptable rate of complications, this approach appears preferable to His bundle ablation in young patients with symptomatic paroxysmal atrial fibrillation resistant to antiarrhythmic therapy.     

Predictive value of B-type natriuretic peptide levels in patients with paroxysmal and persistent atrial fibrillation undergoing pulmonary vein isolation

Background  

Atrial fibrillation (AF) is the most common cardiac arrhythmia reducing the health-related quality of life. Radiofrequency catheter ablation (CA) became the therapy of choice in patients with drug-resistant AF with success rates between 30% and 86%. However, CA remains a challenging intervention with major complications in about 5% of cases. Therefore, stratification into high and low success patient groups would be helpful. The aim of this study was to investigate the predictive value of B-type natriuretic peptide (BNP) on the outcome of pulmonary vein isolation (PVI) in patients with paroxysmal (PAF) and persistent (Pers-AF) atrial fibrillation.     

Katheterablation von paroxysmalem Vorhofflimmern – aktuelle Aspekte

Atrial fibrillation is the most common form of arrhythmia worldwide and is associated with potentially severe complications. Apart from antiarrhythmic drug therapy, interventional treatment by catheter ablation has emerged as an effective and safe alternative notably for the paroxysmal form. The pulmonary veins (PV) have been identified as a major source in the setting of paroxysmal atrial fibrillation. Circumferential wide area PV isolation, optimization of procedural techniques and the positioning of an ablation line deep in the left atrium have contributed to the increased success rates; however, the procedure is still associated with potentially severe complications and should therefore be carried out in centers with sufficient case numbers and operators with corresponding training and experience.     

中国经导管消融治疗心房颤动注册研究-2007

目的 分析2007年我国经导管消融治疗心房颤动(房颤)工作的现状.方法 根据各家医院提供的资料,对2007年我国导管消融治疗房颤病例资料进行回顾性分析.结果 截至2008年9月5日,调查共收到40家医院提供的注册登记病例资料2620份,其中男性1719例,女性901例,平均年龄(58.5±11.2)岁.阵发性房颤77.4%,持续性房颤15.7%,长期持续性房颤6.9%.54.1%的患者合并1种或1种以上的基础心脏疾病.左心房内径(38.3±6.3)mm,左心室舒张末期内径(47.8±5.2)mm,左心室射血分数0.63±0.08.经导管消融治疗房颤的主要术式是环肺静脉消融术和环肺静脉消融加必要心房辅助线.消融能源主要为射频,占99.8%.2007年的消融成功率为80.3%,复发率为19.7%.对成功率和复发率有显著影响的因素有左心房内径、房颤类型和消融术式.术后抗心律失常药物的应用有所增多,抗凝治疗明显加强.总的并发症发生率为1.7%,无严重并发症如心房食管瘘和肺静脉狭窄发生.结论 建议在相关条件较好的医院,可将经导管消融作为症状明显的阵发性房颤的一线治疗方法. 舒张末期内径(47.8±5.2)mm,左心室射血分数0 63±0.08.经导管消融治疗房颤的主要术式是环肺静脉消融术和环肺静脉消融加必要心房辅助线.消融能源主要为射频,占99.8%.2007年的消融成功率为80.3%,复发率为19.7%.对成功率和复发率有显著影响的因素有左心房内径、房颤类型和消融术式.术后抗心律失常药物的应用有所增多,抗凝治疗明显加强.总的并发症发生率为1.7%,无严重并发症如心房食管瘘和肺静脉狭窄发生.结论建议在相关条件较好的医院,可将经导管消融作为症状明显的阵发性房颤的一线治疗方法. 舒张末期内径(47.8±5.2)mm,左心室射血分数0 63±0.08.经导管消融治疗房颤的主要术式是环肺静脉消融术和环肺静脉消融加必要心房辅助线.消融能源主要为射频,占99     

Clinical Results with Catheter Ablation: AV Junction, Atrial Fibrillation and Ventricular Tachycardia

With the limitations of pharmacologic and device therapies for atrial fibrillation and ventricular tachycardia, catheter ablation is assuming a larger role in the management of patients with these common arrhythmias. Multiple case series and clinical trials have helped to define the evolving role of these techniques for ablation of the atrioventricular node, atrial fibrillation, and ischemic ventricular tachycardia. Based on very low complication rates, excellent efficacy and proven outcomes with radiofrequency ablation of the atrioventricular node, this approach with permanent pacing should play a larger role in the treatment of symptomatic patients with permanent atrial fibrillation. While linear ablation of atrial fibrillation has limited clinical utility for the treatment of this common arrhythmia, the results of multiple case series of focal atrial fibrillation ablation indicate the potential for an expanding role of this curative technique. Catheter ablation techniques for ventricular tachycardia in the setting of coronary artery disease have a role as supplemental therapy to the implantable cardioverter defibrillator in patients with recurrent pharmacologically refractory ventricular arrhythmias requiring frequent device interventions.     

Effect of catheter ablation on quality of life of patients with paroxysmal atrial fibrillation

BACKGROUND: Although improved quality of life is one of the primary aims of catheter ablation for paroxysmal atrial fibrillation, there is a paucity of published data on this topic. OBJECTIVES: The purpose of this study was to determine the effect of curative catheter ablation on the quality of life of patients with symptomatic, drug-refractory paroxysmal atrial fibrillation. METHODS: This was a prospective nonrandomized study of 63 consecutively enrolled patients (49 men and 14 women, age 56 +/- 7 years). Patients were excluded from the study if they had significant structural heart disease. The ablation strategy consisted of systematic isolation of all pulmonary veins, followed by limited linear ablation in the atria comprising left isthmus ablation (between the left inferior pulmonary vein and lateral mitral annulus) and cavotricuspid isthmus ablation. Patients completed quality-of-life questionnaires comprising the SF-36 and Symptom Checklist at baseline and 3 and 12 months following ablation. RESULTS: Fifty-four patients (86%) were free of symptomatic recurrence at 12-month follow-up. Successful ablation resulted in a significant improvement of all eight subscales of the SF-36 and of symptom frequency and severity scores of the symptom checklist at 3 months. This improvement was maintained at 12 months. CONCLUSIONS: Combined pulmonary vein isolation and linear atrial ablation has a high success rate for cure of paroxysmal atrial fibrillation. Successful curative catheter ablation of paroxysmal atrial fibrillation significantly and persistently improved quality of life during long-term follow-up. This improvement in quality of life was accompanied by a significant reduction in arrhythmia symptom frequency and severity.     

70岁以上心房颤动患者导管射频消融治疗临床分析

目的 分析70岁以上心房如动(房颤)患者导管射频消融治疗成功率及术后复发危险因素.方技,选择导管射频消融的70岁以上房颤患者107例,收集患者临床和电生理资料,采用Cox比例风险回归模型分析房颤消融术后复发危险因素.结果 107例患者中,阵发性房颤89例.持续性房颤18例.平均随访(25.2±11.5)个月,单次消融成...     

Curative catheter ablation for atrial fibrillation

Optional statement With the recent advances in the understanding of the mechanisms of atrial fibrillation, radiofrequency catheter ablation has emerged as an effective therapeutic modality for patients with atrial fibrillation. Techniques for catheter ablation evolved from elimination of triggers that often originate within the pulmonary veins and initiate atrial fibrillation, to additional left atrial ablation using a variety of approaches to also eliminate the mechanisms that play a role in perpetuation of atrial fibrillation. With the current ablation strategies, atrial fibrillation can be eliminated in approximately 85% of patients with paroxysmal, and in approximately 70% of patients with chronic, atrial fibrillation with a low incidence of significant complications. In symptomatic patients with paroxysmal or chronic atrial fibrillation who have failed antiarrhythmic drug therapy, catheter ablation is an effective treatment strategy for maintenance of sinus rhythm.     

CARTO标测下导管消融治疗房性心律失常的效果

目的：探讨三维电磁导管定位系统（CARTO）指导下3种常见房性心律失常（房性心动过速、心房扑动和心房颤动）导管消融临床的疗效及电生理特征。方法：2008年7月～2013年7月在我院行CARTO指导下导管消融治疗的166例房性心律失常患者的临床应用和电生理资料进行回顾性分析。结果：①166例房性心律失常患者,其中32例为房性心动过速,26例心房扑动,108例心房颤动（阵发性心房颤动78例、持续性房颤30例）;②消融及随访结果：共计162例即刻消融成功,4例失败（房速3例、房扑1例）,总成功率为97．6％;随访6—60个月,复发30例,其中房速、房扑各2例,均再次消融成功;心房颤动复发24例（阵发性心房颤动14例、持续性心房颤动10例）,再次消融后8例成功,二次房颤消融成功率为85％;均未出现心包填塞、心房食管瘘等严重并发症。结论：CARTO三维标测下导管消融治疗房性心动过速、心房扑动、心房颤动等房性心律失常是安全有效的。     

持续性心房颤动导管消融方法及策略

心房颤动是临床上最常见的心律失常,其节律控制治疗主要有药物治疗和非药物治疗两种方式。目前非药物治疗心房颤动发展迅速,其中导管消融作为非药物治疗心房颤动手段之一已被人们广泛接受。肺静脉电隔离作为阵发性心房颤动的消融终点已经得到共识,而持续性心房颤动消融术式及终点尚未统一,现就目前持续性心房颤动消融方法及策略做一简要介绍。     

Vorhofflimmerablation: Wer kommt in Frage?

Atrial fibrillation ablation is, since the introduction of the guidelines in 2006 and which were updated in 2007, now a standard procedure in many electrophysiological centers. Pulmonary vein isolation has proven itself as a way to eliminate focal triggers. From pathophysiological studies of atrial fibrillation development, it is known that ablation performed early in paroxysmal atrial fibrillation has the highest chance for success. In patients with persistent or permanent atrial fibrillation, success rates are lower and repeat interventions are needed more often. Therefore, continuation of antiarrhythmic drug therapy is often necessary in these patient groups. Thus, the curative use of ablation for atrial fibrillation is only possible with the current techniques for patients with paroxysmal atrial fibrillation.     

Ablation von persistierendem und lange persistierendem Vorhofflimmern

Catheter ablation for paroxysmal atrial fibrillation is a meanwhile established therapy option, which is most frequently performed using radiofrequency ablation. Mid-term success rate of 70?% are achievable with a single ablation procedure. However, the mechanistics of persistent atrial fibrillation are less well understood and catheter ablation is a far more challenging procedure. Different ablation approaches are being performed to treat persistent atrial fibrillation ranging from sole pulmonary vein isolation to additional ablation of fractionated electrograms aiming for termination of atrial fibrillation. Thus far, it has not been investigated which strategy is most successful in treating persistent atrial fibrillation. After extended ablation of atrial fibrillation, occurrence of organized atrial arrhythmias is not uncommon and can be successfully ablated. These consecutive arrhythmias can be considered as a next step towards stable sinus rhythm after repeat ablation. Improvement of mapping methods as well as a better understanding of mechanisms of atrial fibrillation may increase success rate of catheter ablation of persistent atrial fibrillation and may also help to improve success rate of these complex procedures.     

Catheter ablation of atrial flutter due to amiodarone therapy for paroxysmal atrial fibrillation.

AIMS: Antiarrhythmic drug treatment for atrial fibrillation can cause atrial flutter-like arrhythmias. The aim of this study was to clarify the effect of catheter ablation of the tricuspid annulus-vena cava inferior isthmus on amiodarone-induced atrial flutter and to determine the incidence of atrial fibrillation after catheter ablation of amiodarone-induced atrial flutter in comparison to regular typical flutter. METHODS AND RESULTS: Among 92 consecutive patients with typical atrial flutter who underwent isthmus ablation 28 patients had atrial flutter without a history of previous atrial fibrillation (group I), 10 patients had atrial flutter following the initiation of amiodarone therapy for paroxysmal atrial fibrillation (group II) and 54 patients had atrial flutter and atrial fibrillation (group III). Atrial cycle length during atrial flutter in amiodarone-treated patients (group II) (277+/-24 ms) was significantly longer as compared to the cycle length of atrial flutter in group I (247+/-33 ms) and group III patients (235+/-28 ms). The rate of successful transient entrainment and overdrive stimulation to sinus rhythm was not different between patients with (60%) or without amiodarone therapy (group I: 71%, group III: 53%). Successful isthmus ablation with bidirectional conduction block eliminating right atrial flutter was achieved in 90% of amiodarone-treated patients and 93% of patients without amiodarone therapy. In the amiodarone-treated patient group atrial conduction times during pacing in sinus rhythm were significantly prolonged by 20-30% before and after ablation in all regions of the reentrant circuit. During a mean follow-up of 8+/-3 months post-ablation, atrial fibrillation recurred in two of 10 patients on continued amiodarone therapy after successful isthmus ablation. Thus, successful catheter ablation of atrial flutter due to amiodarone therapy was associated with a markedly lower recurrence rate of paroxysmal atrial fibrillation (20%) as compared to patients with atrial flutter plus preexisting paroxysmal atrial fibrillation (76%) and was similar to the outcome of patients with successful atrial flutter ablation without preexisting atrial fibrillation (25%). CONCLUSION: These data suggest that isthmus ablation with bidirectional block and continuation of amiodarone therapy is an effective therapy for the treatment of atrial flutter due to amiodarone therapy for paroxysmal atrial fibrillation.     

药物治疗肺静脉和腔静脉电隔离术后阵发性心房颤动

目的 探讨阵发性心房颤动肺静脉和腔静脉电隔离术后早期复发患者药物治疗方法。方法 阵发性心房颤动患者32例，行肺静脉和腔静脉电隔离术后，均给予美托洛尔治疗，早期复发患者加用普罗帕酮，若仍不能控制心房颤动发作，则给予索他洛尔替代上述两药。结果 美托洛尔加普罗帕酮控制阵发性心房颤动的有效率54％。索他洛尔的有效率达83％。控制心房颤动总有效率92％，未发现严重不良反应。所用剂量小于常规剂量。结论 美托洛尔加小剂量的普罗帕酮，或单用小剂量索他洛尔可有效地控制阵发性心房颤动肺静脉和腔静脉电隔离术后早期复发患者的发作。     

Atrial fibrillation triggered by postinfarction ventricular premature beats in a patient with Wolff-Parkinson-White syndrome.

The mechanism by which atrial fibrillation is initiated in patients with accessory pathways is not fully understood. Retrograde conduction of ventricular premature beats to the atrium, causing the arrhythmia, is a very rare cause. We report a patient with Wolff-Parkinson-White syndrome (WPW), without previous tachycardias, who presented multiple episodes of paroxysmal atrial fibrillation after having a myocardial infarction. During the electrophysiological (EP) study the patient presented two spontaneous episodes of atrial fibrillation initiated by ventricular premature beats conducted to the atria through the accessory pathway. After successful catheter ablation of the accessory pathway the patient did not present arrhythmia recurrences.     

Catheter Ablation for Long-Standing Persistent Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and represents a major burden to health care systems. Atrial fibrillation is associated with a 4- to 5-fold increased risk of thromboembolic stroke. The pulmonary veins have been identified as major sources of atrial triggers for AF. This is particularly true in patients with paroxysmal AF but not always the case for those with long-standing persistent AF (LSPAF), in which other locations for ectopic beats have been well recognized. Structures with foci triggering AF include the coronary sinus, the left atrial appendage (LAA), the superior vena cava, the crista terminalis, and the ligament of Marshall. More than 30 studies reporting results on radiofrequency ablation of LSPAF have been published to date. Most of these are observational studies with very different methodologies using different strategies. As a result, there has been remarkable variation in short- and long-term success, which suggests that the optimal ablation technique for LSPAF is still to be elucidated. In this review we discuss the different approaches to LSPAF catheter ablation, starting with pulmonary vein isolation (PVI) through ablation lines in different left atrial locations, the role of complex fractionated atrial electrograms, focal impulses and rotor modulation, autonomic modulation (ganglionated plexi), alcohol ablation, and the future of epicardial mapping and ablation for this arrhythmia. A stepwise ablation approach requires several key ablation techniques, such as meticulous PVI, linear ablation at the roof and mitral isthmus, electrogram-targeted ablation with particular attention to triggers in the coronary sinus and LAA, and discretionary right atrial ablation (superior vena cava, intercaval, or cavotricuspid isthmus lines).     

进一步推进我国导管消融治疗心房颤动的临床研究

目前,心房颤动（房颤）治疗的研究方向主要有两个,一是导管消融,电生理学家力图通过不断改进消融术式,获取更好的消融效果,以期达到最终根治房颤的目的;二是药物治疗,许多药理学家则希望研制出副作用小、见效快、能长期抑制房颤的抗心律失常药物（AAD）,部分对导管消融治疗房颤效果有疑虑的临床医师也对此抱有很大希望。