Eleftherios Giazitzoglou

Autonomic Denervation Added to Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation : A Randomized Clinical Trial

OBJECTIVES The aim of this study was to investigate whether the combination of conventional pulmonary vein isolation (PVI) by circumferential antral ablation with ganglionated plexi (GP) modification in a single ablation procedure, yields higher success rates than PVI or GP ablation alone, in patients with paroxysmal atrial fibrillation (PAF). BACKGROUND Conventional PVI transects the major left atrial GP, and it is possible that autonomic denervation by inadvertent GP ablation plays a central role in the efficacy of PVI. METHODS A total of 242 patients with symptomatic PAF were recruited and randomized as follows: 1) circumferential PVI (n = 78); 2) anatomic ablation of the main left atrial GP (n = 82); or 3) circumferential PVI followed by anatomic ablation of the main left atrial GP (n = 82). The primary endpoint was freedom from atrial fibrillation (AF) or other sustained atrial tachycardia (AT), verified by monthly visits, ambulatory electrocardiographic monitoring, and implantable loop recorders, during a 2-year follow-up period. RESULTS Freedom from AF or AT was achieved in 44 (56%), 39 (48%), and 61 (74%) patients in the PVI, GP, and PVI+GP groups, respectively (p = 0.004 by log-rank test). PVI+GP ablation strategy compared with PVI alone yielded a hazard ratio of 0.53 (95% confidence interval: 0.31 to 0.91; p = 0.022) for recurrence of AF or AT. Fluoroscopy duration was 16 ± 3 min, 20 ± 5 min, and 23 ± 5 min for PVI, GP, and PVI+GP groups, respectively (p < 0.001). Post-ablation atrial flutter did not differ between groups: 5.1% in PVI, 4.9% in GP, and 6.1% in PVI+GP. No serious adverse procedure-related events were encountered. CONCLUSIONS Addition of GP ablation to PVI confers a significantly higher success rate compared with either PVI or GP alone in patients with PAF.

Rapid pulmonary vein isolation combined with autonomic ganglia modification: A randomized study

BACKGROUND Evidence indicates that the combination of left atrial ganglionated plexi (GP) ablation and pulmonary vein (PV) isolation is beneficial for treatment of paroxysmal atrial fibrillation (AF). OBJECTIVE The purpose of this study was to compare GP and PV ablation with PV isolation alone for treatment of paroxysmal AF. METHODS Sixty-seven patients with paroxysmal AF were randomized to either PV isolation using a circular catheter suitable for both mapping and ablation (PV group) or anatomic GP modification followed by PV isolation (GP+PV group). Patients were seen at monthly visits, and 48-hour ambulatory ECG recordings were obtained every 3 months for a predefined follow-up period of 12 months. Primary endpoint was freedom from AF or other sustained atrial arrhythmia recurrence 3 to 12 months postablation after one or two procedures, without antiarrhythmic medications. RESULTS Recurrence of arrhythmia was documented in 18 (54.5%) patients in the PV group 4.7 ± 1.0 months after ablation, and repeat PV isolation was performed in 7 (21.2%) of these patients 5.1 ± 1.1 months after the first procedure. Recurrence of arrhythmia was documented in 9 (26.5%) patients in the GP+PV group 5.0 ± 1.3 months after ablation, and repeat ablation was performed in 6 (17.6%) of these patients 4.3 ± 0.5 months after the first procedure. At the end of follow-up, 20 (60.6%) patients in the PV group and 29 (85.3%) patients in the GP+PV group remained arrhythmia-free (log rank test, P = .019). CONCLUSION Addition of anatomic GP modification to PV isolation confers significantly better outcomes than PV isolation alone during a follow-up period of 12 months.

Association of Neutrophil Gelatinase-Associated Lipocalin With the Severity of Coronary Artery Disease

Serum neutrophil gelatinase-associated lipocalin (NGAL) concentrations were measured in 73 consecutive patients who underwent first-time angiography for suspected coronary artery disease (CAD), and their associations with angiographic indexes of the severity of CAD (i.e., number of diseased vessels and modified Gensini score) were estimated. Median serum NGAL levels in patients with angiographically confirmed CAD were significantly higher than those in patients with normal coronary arteries (29.0 ng/ml [interquartile range 25.2 to 36.8] vs 22.4 ng/ml [interquartile range 17.34 to 32.0], p = 0.004). Statistically significant correlations were observed between serum NGAL level and the number of diseased vessels (r(s) = 0.390, p = 0.01) and modified Gensini score (r(s) = 0.356, p = 0.002). Using multivariate analysis, serum NGAL level was independently associated with the presence and severity of CAD. In conclusion, serum NGAL levels are significantly higher in the presence of CAD and are correlated with the severity of the disease. Further clinical studies are needed to confirm the use of NGAL as a biomarker for the detection and extent of CAD.

Complex fractionated atrial electrograms at anatomic sites of ganglionated plexi in atrial fibrillation

AIMS To investigate the relationship of complex fractionated atrial electrograms (CFAEs) with the activity of the ganglionated plexi (GP) in the cardiac autonomic nervous system. METHODS AND RESULTS Thirty-two patients (aged 55 +/- 10 years, five females) scheduled for circumferential ablation for paroxysmal atrial fibrillation (AF) were studied. Mapping of CFAEs during AF was performed at the left atrium (LA) and pulmonary vein-atrial junctions, particularly at the locations where GP are commonly located. Complex fractionated atrial electrograms were identified at >or=1 GP site in 22 of 32 patients (68.8%) and >or=1 LA wall site in 11 patients (34.4%, P < 0.001). In the 10 patients without CFAEs at the GP site, only one patient displayed CFAEs at the LA site. At the site of the left superior GP, CFAEs were recorded in 17 of 32 patients (53.1%), and in 14 (43.8%), 10 (31.3%), 13 (40.6%), and 19 (59.4%) patients at the sites of left inferior, right anterior, right inferior GP, and crux GP, respectively. Ten of 11 patients with CFAEs recorded in the LA wall also displayed CFAE in at least one GP. This association was statistically significant (P = 0.05). In 7 of these 11 patients, CFAEs were also recorded in the LA wall sites adjacent to a GP that also displayed CFAEs. CONCLUSION Complex fractionated atrial electrograms at presumed anatomic sites of GP were identified in 68.8% patients with paroxysmal AF. In 11 patients without CFAE at the GP, CFAEs were recorded in the LA wall only in one patient. These findings suggest an association between CFAEs and GP.

Medical personnel and patient dosimetry during coronary angiography and intervention.

Percutaneous coronary interventions are associated with increased radiation exposure compared to most radiological examinations. This prospective study aimed at (1) measuring entrance doses for all in-room personnel, (2) performing an assessment of patient effective dose and intracoronary doses, (3) investigating the contribution of each projection to kerma-area product (KAP) and irradiation time, (4) comparing results with established DRL values in this clinical setting and (5) estimating the risk for fatal cancer to patients and operators. Measurements were performed during 40 consecutive procedures of coronary angiography (CA), half of which were followed by ad hoc coronary angioplasty (PTCA). KAP measurements were used for patients and thermoluminescent dosimetry for the in-room personnel. The mean KAP value per procedure for CA was 29 +/- 9 Gy cm2. Thirty four per cent of KAP was due to fluoroscopy, whereas the remainder (66%) was due to digital cine. Accordingly, the mean KAP value per PTCA procedure was 75 +/- 30 Gy cm2, and contribution of fluoroscopy is 57%. Effective dose per year was estimated to be 0.04-0.05 mSv y(-1) for the primary operator, and 0.03-0.04 mSv y(-1) for those assisting. Corresponding measurements for radiographer and nurse were below detectable level, implying minimal radiation hazards for them. Regarding radiation exposure, coronary intervention is considered a quite safe procedure for both patients and personnel in laboratories with modern equipment and experienced operators as long as standard safety precautions are considered. Exposure optimization though should be constantly sought through continuous review of procedures.

Latent arterial hypertension in apparently lone atrial fibrillation.

Introduction. Longitudinal studies on lone AF are rare and the incidence of hypertension in this population unknown. This study aimed at investigating the incidence of arterial hypertension in patients with apparently lone atrial fibrillation (AF).Methods and Results. Out of 292 consecutive patients presented with permanent or paroxysmal AF, 32 patients were diagnosed as having lone AF according to strict criteria. Three patients were subjected to ablation of the ligament of Marshall, 14 patients to pulmonary vein isolation, and the remainder were treated with beta blockade. Patients were followed-up for a 1–3 year period. During follow-up, 14 patients were diagnosed as having arterial hypertension. Thirteen of them had recurrent AF despite ligament of Marshall ablation (1 patient), pulmonary vein isolation (4 patients) and beta blockade (8 patients). Cox regression analysis revealed that the only significant predictor of development of hypertension was complete or partial response to antiarrhythmic therapy (beta = 3.82, S.E. = 1.22, exp(b) = 45.63, 95% C.I. = 4.17–499.2, p = 0.001), independent of age (beta = −0.01, p = 0.74), sex (beta = −0.91, p = 0.28), left ventricular ejection fraction (beta = 0.06, p = 0.52), left atrial size (beta = 0.58, p = 0.7) and kind of antiarrhythmic therapy (ablation or drug therapy) (beta = 1.36, p = 0.09). In patients with lone AF that did not respond at all to antiarrhythmic therapy, there was a 45.6 times higher risk of diagnosing hypertension during the next 3 years as compared to responders.Conclusion. Approximately 44% of patients with an initial diagnosis of lone AF may represent occult cases of arterial hypertension. In these patients hypertension may affect AF recurrence and treatment outcomes, regardless of the mode of antiarrhythmic therapy used.

Ablation of Superior Pulmonary Veins Compared to Ablation of All Four Pulmonary Veins

Introduction: Isolation of all pulmonary veins (PV) is advocated for treatment of paroxysmal atrial fibrillation (PAF). However, the superior PVs are responsible for most AF triggers, whereas the inferior PVs carry the higher risk for ablation‐induced ostial stenosis. The aim of this study was to compare a superior PV isolation approach with isolation of all PVs for treatment of PAF.

Clinical and angiographic characteristics of patients with coronary artery ectasia

BACKGROUND The relationship of the extent of coronary artery ectasia (CAE) with coronary blood flow in the major epicardial arteries has not been adequately assessed. This study aimed at investigating the association of the topographical extent of CAE with coronary flow velocity and clinical characteristics in patients with isolated CAE and in patients with coexisting obstructive coronary artery disease (CAD). METHODS We reviewed 3764 consecutive coronary angiograms performed at Athens Euroclinic and identified patients with CAE according to standard criteria. The topographical extent of ectasia was considered, and coronary flow velocity was determined using the TIMI frame count (TFC). The severity of CAD was assessed using the modified Gensini index and the number of diseased vessels. Clinical data were correlated with TFC and CAD severity analysis. RESULTS Ectatic lesions were identified in 119 patients. The mean TFC correlated positively with the topographical extent of CAE (rs=0.733, p<0.001). Stepwise multiple linear regression revealed that the topographical extent of CAE and the maximum diameter of the ectatic segment in the corresponding artery are independent predictors of TFC in LAD and RCA. Using multivariate analysis, a history of myocardial infarction was independently associated with CAE extent, and CAD severity. CONCLUSIONS The extent of ectasia in the coronary vasculature is correlated with coronary flow velocity and associated with clinical presentation independent of coexisting significant coronary stenoses.

Complications of transseptal catheterization for different cardiac procedures

BACKGROUND Cardiac tamponade is the main complication of transseptal catheterization that is necessary for a variety of cardiac interventions and electrophysiology procedures. METHODS A retrospective assessment of all consecutive procedures that required transseptal puncture by the same experienced operator (with already >100 previous trans-septal procedures) during the period 2000-2012 was performed. We recorded any puncture-related complications of pericardial effusion and cardiac tamponade (acute or delayed). RESULTS A total of 393 procedures were retrieved: Group 1 [ablation of left-sided accessory pathways (n = 77), atrioventricular nodal reentry tachycardia-left septal access (AVNRT) (n = 12), and Inoue balloon mitral valvuloplasty (n = 27)], and Group 2 [atrial fibrillation (AF) ablation procedures: ostial pulmonary vein isolation (PVI) (including RF (n = 76) and cryo-balloon (n = 30)), circumferential PVI (n = 51), and combined procedures (n = 120)]. In total, 5 cases of tamponade were recorded, four of them were acute and one delayed (occurring 1h after the procedure). All tamponade cases occurred only during or after AF ablation procedures (cryo-balloon ablation = 1, circumferential PVI = 2, and combined procedures = 2). In one case emergency atrial repair following median sternotomy was necessary, and in another a surgical drainage through a limited thoracotomy was performed. The other three cases were treated with pericardiocentesis and drainage for 12h. No patient was on uninterrupted oral anticoagulation during the procedure. CONCLUSIONS AF ablation is associated with a higher incidence of tamponade compared to other procedures that require transseptal access. Such procedures should only be performed in hospitals with access to emergency surgical support.

Comparison of the transseptal approach to the transaortic approach for ablation of Left-Sided accessory pathways in patients with Wolff-Parkinson-White syndrome

Forty-four consecutive patients with Wolff-Parkinson-White syndrome and a left-sided accessory pathway were randomized to either a single-catheter transaortic or a single-catheter transseptal approach. The transseptal approach resulted in decreased procedural duration, radiation exposure, and radiofrequency lesions compared with the transaortic technique.