Esophageal imaging and strategies for avoiding injury during left atrial ablation for atrial fibrillation

BACKGROUND: Part of the esophagus is contiguous to the posterior wall (PW) of the left atrium (LA). Esophageal injury has occurred during LA ablation for atrial fibrillation (AF). The ability to identify the esophagus and monitor LAPW lesions with intracardiac echocardiography (ICE) has not been documented. METHODS: We report an index case of atrioesphageal fistula as a complication of transcatheter ablation of AF. After the index case, we retrospectively reviewed morphologic changes with radiofrequency (RF) delivered at LAPW during pulmonary vein (PV) electrical isolation using an 8-mm tip electrode (up to 70 W at a maximum of 50-52 degrees C for 60 seconds) or Chilli catheter (up to 50 W at a maximum of 40 degrees C for 60 seconds). ICE did not influence lesion application. After the index case, RF power was reduced at areas adjacent to the esophagus (8 mm/30-50 W at 50 degrees C or Chilli/40 W at a maximum of 38 degrees C). Duration of RF, 10-30 seconds, was titrated based on accelerated bubble formation or early echogenic lesion formation. RESULTS: The longitudinal extent of the contiguous LAPW-esophageal wall (length 18-59 mm) was identified in all 152 patients (ages 56 +/- 10 years, 117 men). Preablation LAPW (2.8 +/- 0.7 mm) and contiguous anterior esophageal wall (3.0 +/- 0.8 mm) thickness were noted. A total of 6 +/- 4.9 lesions/patient were delivered to the LAPW contiguous to the esophagus. Echogenic LAPW thickness increased to 7.5 +/- 2.1 mm (vs. 2.8 +/- 0.5 mm preablation) before the index case (n = 70 patients) and 4.7 +/- 1.6 mm (vs. 2.9 +/- 0.6 mm) after the index case (n = 67), with power reduction and titration of duration of energy delivery RF (P <.01) and PV isolation in all. CONCLUSIONS: The LAPW-esophageal region can be identified and monitored with ICE imaging during ablation procedures. RF lesions to the LAPW in PV isolation can produce dramatic morphologic changes immediately adjacent to the anterior esophageal wall. A reduction in power amount and duration as described coupled with online lesion monitoring to further titrate duration (<30 seconds) of power delivery decreases the depth of lesion formation and limits the risk of esophageal involvement.     

56例阵发性心房颤动的临床治疗体会

目的：总结阵发性心房颤动的临床特点和治疗方法.方法：回顾我们收治的56例阵发性心房颤动患者的临床资料,并加以分析比较.结果：房性期前收缩是引起心房颤动的主要因素,采用胺碘酮和螺内酯治疗后,总有效率为92.86%,1年内复发率为17.86% 经过1年的治疗,患者的心功能明显改善.结论：阵发性房颤始动因素房性期前收缩为主,采用胺碘酮和螺内酯治疗,可以使患者有效转复为窦性心律,复发率低,提高患者的心功能.     

多家复方丹参片质量测定

目的：观察经阿托伐他汀干预后,慢性非瓣膜性老年房颤患者血浆溶血磷脂酸（LPA）、血小板活化及内皮细胞功能的改变.方法：分为阿司匹林组和阿司匹林＋阿托伐他汀组.分别检测治疗前、治疗后6月对照组及房颤患者血浆LPA,血小板膜上活化糖蛋白IIb/IIIa复合物、糖蛋白Ib、平均血小板体积MPV及血浆血管性血友病因子vWF.结果：治疗前AF患者血浆LPA、GPIIb/IIIa荧光阳性率、MPV、vWF水平显著高于对照组（P〈0.01）,GPIb荧光阳性率明显低于对照组（P〈0.05）.治疗后6个月,房颤组LPA、GPIIb/IIIa荧光阳性率、MPV水平,vWF较治疗前显著下降,且阿司匹林＋阿托伐他汀组下降更明显（P〈0.01）;GPIb荧光阳性率治疗后上升,阿司匹林＋阿托伐他汀组上升更显著（P〈0.01）.结论：阿托伐他汀可降低血浆LPA,增强血小板活化,减少内皮功能受损,可能降低老年患者AF相关性卒中的发生.     

Alterations in atrial electrophysiology associated with chronic atrial fibrillation in man.

BACKGROUND: The purpose of this study was to determine the changes in atrial electrophysiology associated with chronic persistent atrial fibrillation in man. METHODS AND RESULTS: Atrial monophasic action potential duration at 90% repolarization and the effective refractory period were measured in 13 patients with chronic persistent atrial fibrillation after low-energy endocardial cardioversion, and compared to eight controls without a history of atrial fibrillation. Measurements were made at the right atrial appendage and midlateral right atrial wall at basic, 600 ms and 400 ms drive cycle lengths. In control patients, the effective refractory periods were significantly longer at the atrial appendage than the lateral wall at 600 ms (right atrial appendage 265 ms, midlateral right atrial wall 228 ms, P<0.05), and 400 ms cycle lengths (right atrial appendage 270 ms, midlateral right atrial wall 218 ms, P<0.05), but this was not evident in patients with atrial fibrillation. The monophasic action potentials and effective refractory periods at both atrial sites were shorter in the atrial fibrillation patients compared to controls; however, only the effective refractory periods at atrial appendage at 600 ms (atrial fibrillation 210 ms, controls 265 ms, P<0.001), and 400 ms cycle lengths (atrial fibrillation 200 ms, controls 270 ms, P>0.001) reached statistical significance. Effective refractory period dispersion was significantly greater in controls than in patients with atrial fibrillation (cycle length 600 ms: controls 36, atrial fibrillation 13, P=0.01; cycle length 400 ms: controls 54, atrial fibrillation 18, P<0.01). CONCLUSIONS: In patients without a history of atrial fibrillation, the refractory period at the right atrial appendage is significantly longer than at the midlateral right atrial wall. This 'normal' pattern of atrial refractory dispersion is lost in patients with chronic persistent atrial fibrillation, with marked shortening of the effective refractory period at the right atrial appendage. This may explain the high risk of recurrence of atrial fibrillation following successful electrical cardioversion.     

华法令预防心房纤颤患者并发脑梗死的疗效观察

目的 观察华法令与阿司匹林联用与单用阿司匹林在预防心房纤颤(AF)患者并发脑梗死的疗效差距,探讨心房纤颤患者长期服用华法令的有效性、安全性与可行性.方法 80例心房纤颤患者随机分为华法令组40例与阿司匹林组40例,2组均予拜阿司匹灵100mg/d早餐后顿服,华法令组加用华法令晚饭后口服,起始剂量为2mg/d,1周后若INR(凝血酶原国际标准化比值)未达到2.0～3.0,逐步增加华法令剂量使INR值在2.0～3.0之间.随访3年,比较2组患者脑梗死的发生率、病死率、总病死率(包括脑梗死及非脑梗死事件)、出血事件发生率、严重出血发生率、轻度出血发生率.结果 华法令组和阿司匹林组脑梗死发生分别为2例(5.0%)和6例(15.0%),2组比较,P＜0.01;华法令组和阿司匹林组脑梗死患者死亡分别为0例(0%)和2例(5.0%),2组比较,P＜0.01;总死亡华法令组和阿司匹林组分别为2例(5.0%)和4例(10.0%),P＜0.01;2组发生严重出血均为0例,P＞0.05;华法令组轻度出血发生6例(15.0%),其中皮下出血4例,阿司匹林组发生1例(2.5%),华法令组高于阿司匹林组,P＜0.01,但给予调整剂量后症状消失,不影响继续用药.结论 AF患者在常规使用阿司匹林的基础上加用抗凝药物华法令长期口服,可使脑梗死的发生率、脑梗死患者病死率、总病死率明显降低,在合理监测的情况下并未发生严重出血.建议在能定期监测INR值的AF患者中推广使用,以使更多AF患者受益.     

Primary cardiac diffuse large B cell lymphoma presenting with superior vena cava syndrome

Primary cardiac lymphomas are rare extranodal lymphomas that should be distinguished from secondary cardiac involvement by disseminated non-Hodgkin’s lymphoma. Cardiac lymphomas often mimic other cardiac neoplasms, including myxomas and angiosarcomas, and often require multimodality cardiac imaging, in combination with endomyocardial biopsy, excisional biopsy or pericardial fluid cytology, to establish a definitive diagnosis. A 60-year-old immunocompetent man who presented with superior vena cava syndrome secondary to a right atrial, primary cardiac diffuse large B cell lymphoma (non-Hodgkin’s lymphoma) is described in the present article. The patient had no clinical evidence of disseminated lymphoma and was successfully treated with prompt surgical excision of his atrial mass, followed by anthracycline-based chemotherapy. The patient required multimodality cardiac imaging to accurately identify and plan surgical excision of his cardiac lymphoma. The therapeutic management and clinical and radiological features of primary cardiac lymphoma are reviewed.     

The impact of respiration on left atrial and pulmonary venous anatomy: Implications for image-guided intervention

BACKGROUND: Image-guided intervention using pre-acquired CT/MR 3-dimensional images is an emerging strategy for atrial fibrillation (AF) ablation but may be limited by its use of static images to depict dynamic physiology. The effect of biologic factors such as respiration on the left atrial-pulmonary venous (LA-PV) anatomy is not well understood but is likely to have important implications. Conventional CT/MR imaging is performed during an inspiratory breath-hold, while electroanatomical mapping (EAM) during "quiet" breathing approximates an expiratory breath-hold. This study examined the effects of respiration on LA-PV anatomy and the error introduced by respiration on the integration of EAM with 3D MR imaging. METHODS: Pre-procedural MRI angiography was performed at both end-expiration (EXP) and end-inspiration (INSP) in 20 patients undergoing AF catheter ablation. 3D INSP and EXP surface reconstructions of the LA-PVs were compared. In selected pts, EAM data acquired during the ablation procedure (n=7) were integrated with the 3D MRI datasets. RESULTS: Qualitative assessment of the INSP and EXP 3D images revealed splaying of the PVs and reduction in PV caliber of the right-sided PVs during held inspiration. After aligning these two datasets, the average surface-to-surface distance calculated by region ranged from 1.99mm (right middle PV) to 3.79mm (left superior PV). Registration of the EAM to the MRI models was better for the EXP dataset (2.30+/-0.73mm) than the INSP dataset (3.03+/-0.57mm; p=0.004). CONCLUSION: There are significant changes in LA-PV anatomy with respiration. MR images acquired during standard held inspiration may introduce unnecessary errors in registration during image-guided intervention.     

Assessment of left atrial wall velocities by pulsed wave tissue Doppler imaging. A new approach to the study of atrial function

INTRODUCTION AND OBJECTIVES: To analyze the profile of left atrial wall velocities by pulsed wave tissue Doppler imaging, and to compare the relationship between these observations and the transmitral and pulmonary vein flow velocities obtained by conventional pulsed Doppler echocardiography. PATIENTS AND METHOD: We studied 90 patients (50 women and 40 men, mean age 48 [22] years). Pulsed tissue Doppler images of the left atrial wall were obtained and analyzed in all subjects. The study population was then divided in two groups: group I (age < 45 years) and group II (age > 45 years). Transmitral and pulmonary vein flow velocity tracings were obtained simultaneously by pulsed Doppler echocardiography. RESULTS: With pulsed tissue Doppler interrogation of the left atrial wall, a triphasic signal was recorded in all patients, consisting of a positive wave (A1) followed by two negative waves (A2 and A3). Younger subjects (group I) showed a pattern with a prominent A2 wave and an A2/A3 ratio > 1. In older patients (group II) peak velocity of the A2 wave diminished and peak velocity of the A3 wave increased, so that the A2/A3 ratio was < 1. We found no differences in peak velocity of the A1 wave between the two age groups (13.5 (3.9) cm/s in group I vs 13.1 (5.4) cm/s in group II; P = .59). Significant concordance was observed between the transmitral flow pattern and the left atrial pulsed tissue Doppler tracing (kappa = 0.584; P < .0001). CONCLUSIONS: Evaluation of the left atrial wall using pulsed tissue Doppler imaging is feasible and reproducible. Tissue Doppler imaging provides new quantitative insights of potential use in the assessment of left atrial function.     

Right atrium enlargement is related to increased heart damage and mortality in well-controlled hypertension

Background and aimLeft heart remodeling is a well-known pathophysiological effect of arterial hypertension. Right Heart status is not considered in its evaluation. No data are available on right atrium (RA) and its impact on the outcome in hypertension.We wondering to understand whether RA may play a role as a marker of an increased risk for organ damage in well-controlled hypertensives, to probe the clinical significance and whether it could indicate an increased risk.Methods and resultsWe studied well-controlled hypertensive patients. Heart damage was assessed by echocardiography. Patients were subdivided into those with RA area ≤18 cm² (normal RA - Group 1) (554 pts, 227 M, aged 60.35 ± 10.48 years) and those >18 cm² (Increased RA - Group 2) (101 pts, 71 M, age 61.65 ± 9.46 years). Group 2 had a higher left ventricle mass (LVM) and left atrium volume (LAV) both as absolute value (both p < 0.0001) and indexed for body surface area (LVMi p < 0.013; LAVi p = 0.0013). Group 2 showed an increased vascular stiffness (p < 0.0001) and carotid stenosis percentage (p = 0.011). TAPSE (p < 0.0001) resulted significantly increased. In The RA area was significantly correlated directly to LVM and LAV in both groups, but these correlations persisted in indexed values only in Group 2. Moreover, in this group there was a significant direct correlation between RA area and Tricuspid s'wave at echocardiography TDI analysis. Finally, Group 2 had an increased mortality rate compared to Group 1 (Log-Rank p = 0.0006).ConclusionGroup 2 hypertensive patients showed more alterations in dimensional and volumetric left heart parameters, and an increased mortality.