Fred Morady

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

During the past decade, catheter ablation of atrial fibrillation (AF) has evolved rapidly from an investigational procedure to its current status as a commonly performed ablation procedure in many major hospitals throughout the world. Surgical ablation of AF, using either standard or minimally invasive techniques, is also performed in many major hospitals throughout the world. In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society, the European Heart Rhythm Association, and the European Cardiac Arrhythmia Society.1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons and the American College of Cardiology. Since the publication of the 2007 document, there has been much learned about AF ablation, and the indications for these procedures have changed. Therefore the purpose of this 2012 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a Task Force, convened by the Heart Rhythm Society, the European Heart Rhythm Association, and the European Cardiac Arrhythmia Society and charged with defining the indications, techniques, and outcomes of this procedure. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation, including definitions relevant to this topic. This statement summarizes the opinion of the Task Force members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF. This statement is not intended to recommend or promote catheter ablation of AF. Rather the ultimate judgment regarding care of a particular patient …

Catheter Ablation for Paroxysmal Atrial Fibrillation Segmental Pulmonary Vein Ostial Ablation Versus Left Atrial Ablation

Background—Segmental ostial catheter ablation (SOCA) to isolate the pulmonary veins (PVs) and left atrial catheter ablation (LACA) to encircle the PVs both may eliminate paroxysmal atrial fibrillation (PAF). The relative efficacy of these 2 techniques has not been directly compared. Methods and Results—Of 80 consecutive patients with symptomatic PAF (age, 52±10 years), 40 patients underwent PV isolation by SOCA and 40 patients underwent LACA to encircle the PVs. During SOCA, ostial PV potentials recorded with a ring catheter were targeted. LACA was performed by encircling the left- and right-sided PVs 1 to 2 cm from the ostia and was guided by an electroanatomic mapping system; ablation lines also were created in the mitral isthmus and posterior left atrium. The mean procedure and fluoroscopy times were 156±45 and 50±17 minutes for SOCA and 149±33 and 39±12 minutes for LACA, respectively. At 6 months, 67% of patients who underwent SOCA and 88% of patients who underwent LACA were free of symptomatic PAF when not taking antiarrhythmic drug therapy (P =0.02). Among the variables of age, sex, duration and frequency of PAF, ejection fraction, left atrial size, structural heart disease, and the ablation technique, only an increased left atrial size and the SOCA technique were independent predictors of recurrent PAF. The only complication was left atrial flutter in a patient who underwent LACA. Conclusions—In patients undergoing catheter ablation for PAF, LACA to encircle the PVs is more effective than SOCA.

Atrio-Esophageal Fistula as a Complication of Percutaneous Transcatheter Ablation of Atrial Fibrillation

Background—Radiofrequency ablation for atrial fibrillation is becoming widely practiced. Methods and Results—Two patients undergoing circumferential pulmonary vein ablation for atrial fibrillation in different centers developed symptoms compatible with endocarditis 3 to 5 days after the procedure. Their clinical condition deteriorated rapidly, and both suffered multiple gaseous and/or septic embolic events causing cerebral and myocardial damage. One patient survived after emergency cardiac and esophageal surgery; the other died of extensive systemic embolization. An atrio-esophageal fistula was identified in both patients. Conclusions—Atrio-esophageal fistulas can occur after catheter ablation in the posterior wall of the left atrium. This diagnosis should be excluded in any patient with symptoms or signs of endocarditis after left atrial ablation, and expeditious cardiac surgery is critical if the diagnosis is confirmed. Lower power and temperature settings for applications of radiofrequency energy along the posterior left atrial wall may prevent further cases of fistula formation.

Diagnosis and cure of the Wolff-Parkinson-White syndrome or paroxysmal supraventricular tachycardias during a single electrophysiologic test

BACKGROUND We conducted this study to determine the feasibility of an abbreviated therapeutic approach to the Wolff-Parkinson-White syndrome or paroxysmal supraventricular tachycardia, in which the diagnosis is established and radiofrequency ablation carried out during a single electrophysiologic test. METHODS One hundred six consecutive patients were referred for the management of documented, symptomatic paroxysmal supraventricular tachycardias (66 patients) or the Wolff-Parkinson-White syndrome (40 patients). All agreed to undergo a diagnostic electrophysiologic test and catheter ablation with radiofrequency current. No patient had had such a test previously. RESULTS Among the 66 patients with paroxysmal supraventricular tachycardias, the mechanism was found to be atrioventricular nodal reentry in 46 (70 percent) (typical in 44 and atypical in 2), atrioventricular reciprocating tachycardia involving a concealed accessory pathway in 16 (24 percent), atrial tachycardia in 2 (3 percent), and noninducible paroxysmal supraventricular tachycardia in 2 (3 percent). A successful long-term outcome was achieved in 57 of 62 patients (92 percent) with paroxysmal supraventricular tachycardia in whom ablation was attempted and in 37 of 40 patients (93 percent) with the Wolff-Parkinson-White syndrome. The only complications were one instance of occlusion of the left circumflex coronary artery, leading to acute myocardial infarction, and one instance of complete atrioventricular block. The mean (+/- SD) duration of the electrophysiologic procedures was 114 +/- 55 minutes. CONCLUSIONS The diagnosis and cure of paroxysmal supraventricular tachycardia or the Wolff-Parkinson-White syndrome during a single electrophysiologic test are feasible and practical and have a favorable risk-benefit ratio. This abbreviated therapeutic approach may eliminate the need for serial electropharmacologic testing, long-term drug therapy, antitachycardia pacemakers, and surgical ablation.

Preoperative Amiodarone as Prophylaxis against Atrial Fibrillation after Heart Surgery

Background Atrial fibrillation occurs commonly after open-heart surgery and may delay hospital discharge. The purpose of this study was to assess the use of preoperative amiodarone as prophylaxis against atrial fibrillation after cardiac surgery. Methods In this double-blind, randomized study, 124 patients were given either oral amiodarone (64 patients) or placebo (60 patients) for a minimum of seven days before elective cardiac surgery. Therapy consisted of 600 mg of amiodarone per day for seven days, then 200 mg per day until the day of discharge from the hospital. The mean (±SD) preoperative total dose of amiodarone was 4.8±0.96 g over a period of 13 ± 7 days. Results Postoperative atrial fibrillation occurred in 16 of the 64 patients in the amiodarone group (25 percent) and 32 of the 60 patients in the placebo group (53 percent) (P = 0.003). Patients in the amiodarone group were hospitalized for significantly fewer days than were patients in the placebo group (6.5 ± 2.6 vs. 7.9 ± 4.3 days, P = 0.04). ...

Amiodarone versus implantable cardioverter-defibrillator:randomized trial in patients with nonischemicdilated cardiomyopathy and asymptomaticnonsustained ventricular tachycardia—AMIOVIRT

OBJECTIVES The purpose of this multicenter randomized trial was to compare total mortality during therapy with amiodarone or an implantable cardioverter-defibrillator (ICD) in patients with nonischemic dilated cardiomyopathy (NIDCM) and nonsustained ventricular tachycardia (NSVT). BACKGROUND Whether an ICD reduces mortality more than amiodarone in patients with NIDCM and NSVT is unknown. METHODS One hundred three patients with NIDCM, left ventricular ejection fraction < or =0.35, and asymptomatic NSVT were randomized to receive either amiodarone or an ICD. The primary end point was total mortality. Secondary end points included arrhythmia-free survival, quality of life, and costs. RESULTS The study was stopped when the prospective stopping rule for futility was reached. The percent of patients surviving at one year (90% vs. 96%) and three years (88% vs. 87%) in the amiodarone and ICD groups, respectively, were not statistically different (p = 0.8). Quality of life was also similar with each therapy (p = NS). There was a trend with amiodarone, as compared to the ICD, towards improved arrhythmia-free survival (p = 0.1) and lower costs during the first year of therapy (

Radiofrequency catheter ablation of ventricular tachycardia in patients with coronary artery disease.

8,879 US dollars vs.

Risk of Thromboembolic Events After Percutaneous Left Atrial Radiofrequency Ablation of Atrial Fibrillation

22,039 US dollars, p = 0.1). CONCLUSIONS Mortality and quality of life in patients with NIDCM and NSVT treated with amiodarone or an ICD are not statistically different. There is a trend towards a more beneficial cost profile and improved arrhythmia-free survival with amiodarone therapy.

Effect of Atrial Fibrillation on Atrial Refractoriness in Humans

BackgroundRadiofrequency (RF) ablation of idiopathic ventricular tachycardia (VT) has been demonstrated to be highly efficacious, but the efficacy of RF ablation of VT in patients with coronary artery disease has been unknown. Therefore, the purpose of this study was to determine the feasibility of RF ablation of VT in patients with coronary artery disease. Methods and ResultsFifteen consecutive patients with coronary artery disease and a history of myocardial infarction underwent an attempt at RF ablation of 16 hemodynamically stable monomorphic VTs that had been documented clinically on a 12-lead ECG and that had not been successfully managed by pharmacological or device therapy. One VT was incessant, five occurred more than 25 times, and the remainder occurred two to 20 times. An additional four VTs that had not been documented clinically also were targeted for ablation. The mean age of the patients was 68±7 years (±|SD), and their mean left ventricular ejection fraction was 0.27±0.08. The mean cycle length of the 20 VTs targeted for ablation was 438±82 msec. Ablation sites were selected based on endocardial activation mapping, pace mapping, identification of an isolated middiastolic potential, or concealed entrainment. Sixteen of the 20 VTs (80%o) were successfully ablated in 11 of 15 patients (73%), using a mean of 4.2±3 applications ofRF energy, and no recurrences of the ablated VTs occurred during 9.1±3.3 months of follow-up. The mean duration of the ablation procedures was 128±30 minutes. No complications occurred in any of the patients. ConclusionThe results of this study demonstrate that RF ablation of hemodynamically stable is feasible as adjunctive therapy in selected patients with coronary artery disease.

Radiofrequency catheter ablation of accessory atrioventricular connections in 250 patients. Abbreviated therapeutic approach to Wolff-Parkinson-White syndrome.

Background— In patients with atrial fibrillation (AF), the risk of thromboembolic events (TEs) is variable and is influenced by the presence and number of comorbid conditions. The effect of percutaneous left atrial radiofrequency ablation (LARFA) of AF on the risk of TEs is unclear. Methods and Results— LARFA was performed in 755 consecutive patients with paroxysmal (n=490) or chronic (n=265) AF. Four hundred eleven patients (56%) had ≥1 risk factor for stroke. All patients were anticoagulated with warfarin for ≥3 months after LARFA. A TE occurred in 7 patients (0.9%) within 2 weeks of LARFA. A late TE occurred 6 to 10 months after ablation in 2 patients (0.2%), 1 of whom still had AF, despite therapeutic anticoagulation in both. Among 522 patients who remained in sinus rhythm after LARFA, warfarin was discontinued in 79% of 256 patients without risk factors and in 68% of 266 patients with ≥1 risk factor. Patients older than 65 years or with a history of stroke were more likely to remain anticoagulated despite a successful outcome from LARFA. None of the patients in whom anticoagulation was discontinued had a TE during 25±8 months of follow-up. Conclusions— The risk of a TE after LARFA is 1.1%, with most events occurring within 2 weeks after the procedure. Discontinuation of anticoagulant therapy appears to be safe after successful LARFA, both in patients without risk factors for stroke and in patients with risk factors other than age >65 years and history of stroke. Sufficient safety data are as yet unavailable to support discontinuation of anticoagulation in patients older than 65 years or with a history of stroke.