Cai-Hua Sang

Additional Ablation of Complex Fractionated Atrial Electrograms After Pulmonary Vein Isolation in Patients With Atrial Fibrillation A Meta-Analysis

Background— The efficacy of additional complex fractionated atrial electrogram (CFAE) ablation after pulmonary vein antrum isolation (PVAI) in patients with atrial fibrillation (AF) remains controversial. This meta-analysis was performed to assess the additional efficacy of CFAEs ablation after a single procedure without antiarrhythmic drugs. Methods and Results— Trials were identified in MEDLINE, Cochrane Library, Embase, Google Scholar, reviews, and reference lists of relevant papers. Controlled cohort studies comparing the long-term efficacy of combined CFAEs plus PVAI ablation with PVAI alone were included. The primary end point was the maintenance of sinus rhythm without antiarrhythmic drugs. Seven controlled trials (9 comparisons) with a total of 622 participants (332 patients underwent PVAI plus CFAE ablation and 330 patients underwent PVAI alone) were included in the meta-analysis. In an overall pooled estimate, compared with PVI alone, long-term rates of sinus rhythm maintenance (relative risk, 1.17, 95% confidence interval, 1.03 to 1.33, P=0.019) were increased by additional CFAE ablation. Subgroup analysis demonstrated that additional CFAEs ablation increased rates of sinus rhythm maintenance in nonparoxysmal AF (relative risk, 1.35; 95% confidence interval, 1.04 to 1.75; P=0.022), whereas had no effect on patients with paroxysmal AF (relative risk, 1.04; 95% confidence interval, 0.92 to 1.18; P=0.528). Conclusions— Adjuvant CFAE ablation in addition to standard PVAI increases the rate of long-term sinus rhythm maintenance in nonparoxysmal AF patients after a single procedure without antiarrhythmic drugs but does not provide additional benefit to sinus rhythm maintenance in paroxysmal AF patients.

Serum uric acid and risk of left atrial thrombus in patients with nonvalvular atrial fibrillation.

BACKGROUND Serum uric acid (SUA) is a simple and independent marker of morbidity and mortality in a variety of cardiovascular diseases. In this study we aimed to investigate SUA and the risk of left atrial (LA) thrombus in patients with nonvalvular atrial fibrillation (AF). METHODS In this retrospective study, 1359 consecutive patients undergoing transesophageal echocardiography before catheter ablation of AF were enrolled. Sixty-one of the 1359 patients (4.5%) had LA thrombus. RESULTS SUA levels in patients with LA thrombus were significantly greater (413.5 ± 98.8 μmol/L vs 366.7 ± 94.3 μmol/L; P < 0.001). Hyperuricemia was defined as SUA ≥ 359.8 μmol/L in women and ≥ 445.6 μmol/L in men determined according to receiver operating characteristic curve. The incidence of LA thrombus was significantly greater in patients with hyperuricemia than in those with a normal SUA level in women (12.1% vs 1.9%; P < 0.001) and in men (8.5% vs 2.8%; P < 0.001). Hyperuricemia had a negative predictive value of 98.1% in women and 97.1% in men for identifying LA thrombus. Hyperuricemia was associated with significantly greater risk of LA thrombus among Congestive Heart Failure, Hypertension, Age ≥ 75 Years, Diabetes Mellitus, Stroke, Vascular Disease, Age 65 to 74 Years, Sex Category (CHA2DS2-VASc) score = 0, 1, and ≥ 2 groups with odds ratios of 7.19, 4.05, and 3.25, respectively. In multivariable analysis, SUA was an independent risk factor of LA thrombus (odds ratio, 1.004; 95% confidence interval, 1.000-1.008; P = 0.028). CONCLUSIONS Hyperuricemia was a modest risk factor for LA thrombus, which might refine stratification of LA thrombus in patients with nonvalvular AF.

Current Status and Time Trends of Oral Anticoagulation Use Among Chinese Patients With Nonvalvular Atrial Fibrillation: The Chinese Atrial Fibrillation Registry Study

Background and Purpose— Reported rates of oral anticoagulation (OAC) use have been low among Chinese patients with atrial fibrillation (AF). With improved awareness, changing guidelines, this situation may be changing over time. We aimed to explore the current status and time trends of OAC use in Beijing. Methods— We used the data set from the Chinese Atrial Fibrillation Registry (CAFR), a prospective, multicenter, hospital-based registry study involving 20 tertiary and 12 nontertiary hospitals in Beijing. A total of 11 496 patients with AF were enrolled from 2011 to 2014. Results— Seven thousand nine hundred seventy-seven eligible patients were included in this ancillary study. The proportions of OAC use were 36.5% (2268/6210), 28.5% (333/1168), and 21.4% (128/599) for patients with CHA2DS2-VASc scores ≥2, 1, and 0, respectively. Persistent AF, history of stroke/transient ischemic attack/peripheral embolism, diabetes mellitus, higher body mass index, and tertiary hospital management were factors positively associated with OAC use, whereas older age, previous bleeding, hypercholesterolemia, and established coronary artery disease were factors negatively associated with OAC use. Among patients with CHADS2 scores ≥2 and CHA2DS2-VASc scores ≥2, the proportion of OAC use increased from 31.3% to 64.5% and 30.2% to 57.7%, respectively, from 2011 to 2014. Variation in OAC use was substantial among different hospitals. Conclusions— An improvement of OAC use among Chinese patients with AF in Beijing is observed in recent years although only 36.5% of patients with CHA2DS2-VASc score ≥2 received OAC. However, variations between different hospitals were large, suggesting that better education and awareness are needed to improve efforts for stroke prevention among AF patients. Clinical Trial Registration— URL: http://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729.

A New Method to Evaluate Linear Block at the Left Atrial Roof: Is It Reliable Without Pacing?

A New Method to Evaluate Linear Block at the Left Atrial Roof. Objective: The present study aimed to evaluate a new method for validation of complete linear block at the left atrial (LA) roof.

Isolated Conduction Within the Left His-Purkenje System During Sinus Rhythm and Idiopathic Left Ventricle Tachycardia Findings From Mapping the Whole Conduction System

Background—Functionally, left His-Purkenje system (HPS) is insulated from the adjacent myocardium and exhibits isolated conduction during sinus rhythm (SR), but in vivo human study is rare. Meanwhile, whether the isolated conduction also exists during idiopathic left ventricle tachycardia (ILVT) is not clearly defined. The current study aimed to delineate the activation sequence and gross anatomy of left HPS during SR and ILVT. Methods and Results—The study involved 25 consecutive patients with ILVT. During SR, left HPS exhibited antegrade activation sequence, and its surrounding myocardium depolarized after HPS in an apical to base direction. During ILVT, the earliest retrograde presystolic potentials were mainly located at the middle portion of left posterior fascicle (0.5±0.1 [95% confidence interval, 0.46–0.58] of its full length) with an average of 29.5±6.0 mm (19.8–41.5) away from the His position. Left posterior fascicle was depolarized from the earliest retrograde presystolic potentials via 2 opposite wavefronts with significantly shorter activation time than that during SR (15.1±2.1 versus 30.0±3.2 ms; P<0.001). The left anterior fascicle was depolarized after left posterior fascicle with an antegrade activation sequence and comparable activation time with that during SR (21.9±2.9 versus 22.0±4.1 ms; P=0.932). The depolarization of ventricle septum also occurred after HPS in an apical to base direction. Conclusions—During SR, isolated conduction within the HPS is demonstrated by documenting the reverse activation sequence with its surrounding myocardium. During ILVT, the earliest retrograde presystolic potentials were usually recorded at the middle segment of left posterior fascicle, and the isolated conduction within the HPS remained.

Ablation of Right-Sided Accessory Pathways With Atrial Insertion Far From the Tricuspid Annulus Using an Electroanatomical Mapping System

Ablating Right‐Sided Accessory Pathways With Atrial Insertions Far From Tricuspid Annulus. Background: It is difficult to ablate a right‐sided accessory pathway (AP) with atrial insertion far from the tricuspid annulus (TA). We report our initial experience of ablating this rare AP by a 3‐dimensional electroanatomical mapping system (CARTO).

Transseptal Puncture Through Amplatzer Septal Occluder Device for Catheter Ablation of Atrial Fibrillation: Use of Balloon Dilatation Technique

Transseptal Puncture Through Amplatzer Device. Transseptal puncture is required for catheter ablation of atrial fibrillation. We report on a 59‐year‐old woman presenting with atrial fibrillation after transcatheter closure of a large‐sized secundum atrial septal defect with an Amplatzer septal occluder. Direct transseptal access through the device was achieved with the aid of an angioplasty balloon and atrial fibrillation was successfully ablated. Such an approach of transseptal puncture can facilitate obtaining left atrial access in complicated intervention procedures.

Significant Left Atrial Appendage Activation Delay Complicating Aggressive Septal Ablation during Catheter Ablation of Persistent Atrial Fibrillation

Background:  This study aims to describe significant left atrial appendage activation following ablation of persistent atrial fibrillation, and explore its relationship with aggressive septal ablation.

Plasma homocysteine levels predict early recurrence after catheter ablation of persistent atrial fibrillation

Aims To assess the association and the predictive value of plasma homocysteine (Hcy) with early recurrence in persistent atrial fibrillation patients after a single ablation procedure. Methods and results Two hundred and fifty-seven consecutive patients with persistent atrial fibrillation who underwent successful catheter ablation were enrolled. Early recurrence of atrial tachyarrhythmia was documented within 3 months after ablation. The logistic regression analysis and Kaplan–Meier curve analysis were used to evaluate the association of Hcy with early recurrence. During the 3-month follow-up, 75 (29.2%) patients experienced recurrence. Patients with early recurrence were older, more likely to have larger left atrial diameter and higher CHA2DS2-VASc score (all P< 0.001). Plasma Hcy levels were significantly elevated in patients with early recurrence compared with those without early recurrence (15.1 ± 4.1 vs. 12.4 ± 3.7 µmol/L, P< 0.001). In multivariate analysis, Hcy was significantly associated with early recurrence (OR 1.188, 95% CI 1.097–1.286, P< 0.001). Hcy demonstrated a predictive value with AUC of 0.688 (95% CI 0.623–0.753, P< 0.001). The optimal cut-off value was 14 µmol/L for Hcy (sensitivity 69%, specificity 59%). Patients with Hcy ≥14 µmol/L had higher early recurrence rate compared with those with Hcy <14 µmol/L (41 vs. 22%, P= 0.006). Conclusion Plasma Hcy levels are associated with early recurrence of atrial tachyarrhythmia after catheter ablation in persistent atrial fibrillation patients, thus it should be taken into account in prediction of early recurrence.

Incidence and clinical characteristics of transient ST-T elevation during transseptal catheterization for atrial fibrillation ablation

AIMS Transient ST-T elevation (STE) is a rare complication that occurs during transseptal catheterization. This study aims to delineate the incidence and characteristics of transient STE during transseptal catheterization for atrial fibrillation (AF) ablation. METHODS AND RESULTS Consecutive patients who underwent fluoroscopy-guided transseptal catheterization for circumferential pulmonary vein radiofrequency ablation in Beijing An Zhen Hospital from January 2006 to January 2013 were enrolled in this study. Out of 2965 patients with a total of 3452 transseptal catheterization procedures, 13 patients (0.38%, mean age 57 ± 8, 6 female, 12 paroxysmal AF, mean left atrial diameter 35.4 ± 3.8 mm) had STE. ST-T elevation occurred after transseptal puncture in 10 patients and after pulmonary vein venography in three patients. Systolic blood pressure (129 ± 10 vs. 104 ± 20 mmHg, P < 0.001), diastolic blood pressure (78 ± 6 vs. 64 ± 11 mmHg, P < 0.001), and heart rate (83 ± 19 bpm vs. 64 ± 23 b.p.m., P = 0.022) significantly decreased when STE occurred. Eleven patients complained of chest pain, one patient complained of dizziness, and one patient had no symptoms. Patients recovered in about 4.6 min (2-10 min) with dopamine or fast saline drip. Catheter ablation of AF was completed in all the 13 patients without sequelae or other complications. Four of the 13 patients (30.8%) had recurrence of AF after a mean follow-up of 21.7 months. CONCLUSION ST-T elevation is a rare complication associated with transseptal catheterization without sequelae. Catheter ablation of AF could be safely completed in these patients.