Lihui Zheng

Endocardial Autonomic Denervation of the Left Atrium to Treat Vasovagal Syncope An Early Experience in Humans

Background— Vasovagal syncope (VVS) is the most common cause of recurrent syncope that can be debilitating despite optimal conventional therapy. The aim of this study was to evaluate the feasibility and efficacy of selective endocardial autonomic denervation in left atrium (LA) as an alternative treatment strategy in patients with highly symptomatic VVS. Methods and Results— Ten consecutive patients (mean age, 50.4±6.4 years; 7 women) with a medium of 3.5 (range, 2–20) recurrent episodes of VVS during the preceding year and positive head-up tilt testing in whom standard therapies were ineffective or poorly tolerated were enrolled. Ganglionated plexi (GP) in the LA, identified by high-frequency stimulation, was targeted by radiofrequency catheter ablation. The patients were then followed up at 3, 6, 12, 24, and 36 months, including repeated head-up tilt testing and Holter at 3 and 12 months. Radiofrequency energy was applied at the left superior GP in 10 patients, right anterior GP in 5, and left inferior GP in 3, using an 8-mm ablation catheter. Vagal response, defined as transient ventricular asystole, atrioventricular block, or an increase in R-R interval by 50%, was observed during ablation in all GP sites. The end point of procedure was the inhibition of the vagal response at target sites. At 30±16 (range, 13–55) months of follow-up, no patient had any recurrence of syncope and all patients had significant improvement in symptoms, but 5 of 10 patients reported transient prodromes. No complications occurred. Conclusions— Comprehensive endocardial autonomic denervation of the LA demonstrates the feasibility of treating VVS in medium-term follow-up.

Impact of Alcohol Consumption on Substrate Remodeling and Ablation Outcome of Paroxysmal Atrial Fibrillation

Background The effect of alcohol consumption on substrate remodeling and ablation outcome of paroxysmal atrial fibrillation (PAF) remains unknown. Methods and Results We performed circumferential pulmonary vein isolation (CPVI) and voltage mapping of left atrium (LA) during sinus rhythm in 122 consecutive patients with symptomatic PAF (age, 55.4±9.4 years; 73.8% men). Low‐voltage zones (LVZs) were semiquantitatively estimated and presented as low‐voltage index (LVI). Each patients daily alcohol consumption history was recorded at baseline and classified into alcohol abstainers, moderate drinkers, and heavy drinkers based on the National Institute on Alcohol Abuse and Alcoholism definition. Follow‐up was ≥12 months for AF recurrence. Alcohol abstainers and moderate and heavy drinkers were 70 (57.4%), 13 (10.6%), and 39 (32.0%), respectively. In total, LVZs were observed in 44 patients (36.1%). Daily alcohol consumption independently predicted presence of LVZs (odds ratio [OR], 1.097; 95% confidence interval [CI], 1.001–1.203; P=0.047). During mean follow‐up of 20.9±5.9 months, 40 patients (35.1%) experienced AF recurrence. Success rate was 81.3%, 69.2%, and 35.1% in alcohol abstainers, moderate drinkers, and heavy drinkers, respectively (overall log rank, P<0.001). Multivariate analysis showed that both alcohol consumption and LVI were independent predictors of AF recurrence (hazard ratio [HR], 1.579; 95% CI, 1.085–2.298; P=0.017; HR, 2.188; 95% CI, 1.582–3.026; P<0.001, respectively). Furthermore, mediation analysis revealed that LVZs acted as a partial mediator in effect of alcohol consumption on AF ablation outcomes. Conclusions Daily alcohol consumption was associated with atrial remodelling, and heavy drinkers have substantial risk for AF recurrence after CPVI.

Long-term follow-up of pure linear ablation for persistent atrial fibrillation without circumferential pulmonary vein isolation.

The long‐term outcome of radiofrequency catheter ablation in persistent atrial fibrillation (AF) patients remains controversial due to different procedural strategies. This study aimed to present the clinical outcome of a pure linear ablation approach without circumferential pulmonary vein isolation (CPVI) over an extended (>5 years) follow‐up period.

Catheter Ablation as a Treatment for Vasovagal Syncope: Long‐Term Outcome of Endocardial Autonomic Modification of the Left Atrium

Background Autonomic modification through catheter ablation of ganglionated plexi (GPs) in the left atrium has been reported previously as a treatment for vasovagal syncope. This study aimed to observe the long‐term outcome in a larger cohort. Methods and Results A total of 57 consecutive patients (aged 43.2±13.4 years; 35 women) with refractory vasovagal syncope were enrolled, and high‐frequency stimulation and anatomically guided GP ablation were performed in 10 and 47 cases, respectively. A total of 127 GP sites with positive vagal response were successfully elicited and ablated, including 52 left superior, 19 left lateral, 18 left inferior, 27 right anterior, and 11 right inferior GPs. During follow‐up of 36.4±22.2 months (range 12–102 months), 52 patients (91.2%) remained free from syncope. Prodromes recurred in 16 patients. No statistical differences were found between the high‐frequency stimulation and anatomically guided ablation groups in either freedom from syncope (100% versus 89.4%, P=0.348) or recurrent prodromes (50% versus 76.6%, P=0.167). The deceleration capacity, heart rate, and heart rate variability measurements demonstrated a reduced vagal tone lasting for at least 12 months after the procedure, with improved tolerance of repeated head‐up tilt testing. No complications were observed except for transient sinus tachycardia that occurred in 1 patient. Conclusions Left atrial GP ablation showed excellent long‐term clinical outcomes and might be considered as a therapeutic option for patients with symptomatic vasovagal syncope.

Comparison of Radiofrequency Catheter Ablation Between Asymptomatic and Symptomatic Persistent Atrial Fibrillation: A Propensity Score Matched Analysis

Whether patients with asymptomatic atrial fibrillation (AF) could benefit from radiofrequency catheter ablation (RFCA) remains unclear. This study aimed to compare the outcomes of RFCA between asymptomatic and symptomatic AF.

Intracardiac thrombosis in patients with arrhythmogenic right ventricular cardiomyopathy.

Intracardiac thrombus has been reported in anecdotal cases of arrhythmogenic right ventricular cardiomyopathy (ARVC). This prospective study aimed to determine the prevalence, risk factors, and prognosis of intracardiac thrombosis in patients with ARVC.

OptiVol fluid index predicts acute decompensation of heart failure with a high rate of unexplained events.

Background Intrathoracic impedance monitoring has emerged as a promising new technique for the detection of impending heart failure (HF). Although false positive episodes have been reported in case reports and clinical trials, the efficacy and false positive rate in real-world practice remain unclear. Objective The aim of this study is to investigate the utility and reliability of the OptiVol alert feature in clinical practice. Methods We continuously recruited patients who underwent implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with defibrillator (CRT-D) implantation with feature of intrathoracic impedance monitoring system in our center from Sep. 2010 to Oct. 2012. Regular in-office follow-up were required of all patients and the following information was collected at each visit: medical history, device interrogation, N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement and an echocardiogram. Worsening HF was defined as hospitalization or the presentation of signs or symptoms of HF. Results Forty three patients (male: 76.7%, mean age: 57 ± 15 years, left ventricular ejection fraction (LVEF): 33% ± 14%) were included in this observational study. Fifty four alert events and 14 adjudicated worsening HF were detected within 288 ±163 days follow-up. Eleven (20.4%) alert episodes were associated with acute cardiac decompensation in 9 patients with a positive predictive value of 78.6%. Forty three audible alerts showed no connection to worsening HF. The unexplained alerts rate was 79.6% and 1.27 per person-year. Thirty seven alarm alerts were detected in patients with EF < 45%, among which 9 accompanied with HF, 17 alerts detected in patients with LVEF ≥ 45% and 2 associated with HF. There was no significant difference between the two groups (9/37 vs. 2/17; P = 0.47). Conclusions Patients with normal or nearly normal left ventricular systolic function also exhibited considerable alert events. The OptiVol fluid index predicted worsening cardiac events with a high unexplained detection rate, and any alert must therefore be analyzed with great caution. Efforts to improve the specificity of this monitoring system represent a significant aspect of future studies.

Relationships of High-sensitive C-reactive Protein and P-wave Dispersion in Lone Atrial Fibrillation

Background:Current evidence links atrial fibrillation (AF) to the inflammation. Inflammatory indexes such as high-sensitive C-reactive protein (hs-CRP) have been related to the development and persistence of AF. However, the role of inflammation in the atrial electrophysiological remodeling indexed by P-wave dispersion (Pd) remains unclear. Methods:The study consisted of 71 patients with lone paroxysmal AF (AF group) and 71 age- and gender-matched controls of paroxysmal supraventricular tachycardia without history of AF (control group). Electrocardiography, Pd, hs-CRP, and other clinical characteristics were compared between the two groups. Results:There was no significant difference between the two groups regarding age, gender, hyperlipidemia, etc. Compared to controls, left atrial diameter (44 ± 7 vs 39 ± 7 mm), Pd (49 ± 13 vs 26 ± 8 ms), and hs-CRP (2.17 [1.46–2.89] vs 1.12 [0.74–1.41] mg/L) were increased (P < 0.05), respectively. Linear regression identified hs-CRP as an independent correlation of Pd level both in the total population and the AF group (r = 0.464 and 0.313; P < 0.001, respectively). Multiple logistic regression revealed hs-CRP as an independent determinant of AF (odds ratio [OR] =15.430, 95% confidence interval: 6.031–39.476: P <0.001). Further adjusted for Pd, both Pd and hs-CRP were independent predictors for AF, but the OR for hs-CRP in predicting AF has been attenuated from 15.430 to 6.246. Conclusions:In lone AF, Pd and plasma hs-CRP concentration are inter-associated and related to AF. The interaction between hs-CRP and AF may be mediated by Pd, suggesting an important role of inflammation in the atrial electrophysiological remodeling predisposing to AF.

Impact of Body Mass Index on Plasma N-Terminal ProB-Type Natriuretic Peptides in Chinese Atrial Fibrillation Patients without Heart Failure

Background An inverse relationship between body mass index (BMI) and circulating levels of N-terminal proB-type natriuretic peptide (NT-proBNP) has been demonstrated in subjects with and without heart failure. Obesity also has been linked with increased incidence of atrial fibrillation (AF), but its influence on NT-proBNP concentrations in AF patients remains unclear. This study aimed to investigate the effect of BMI on NT-proBNP levels in AF patients without heart failure. Methods A total of 239 consecutive patients with AF undergoing catheter ablation were evaluated. Levels of NT-proBNP and clinical characteristics were compared in overweight or obese (BMI≥25 kg/m2) and normal weight (BMI<25 kg/m2) patients. Results Of 239 patients, 129 (54%) were overweight or obese. Overweight or obese patients were younger, more likely to have a history of nonparoxysmal AF, hypertension, and diabetes mellitus. Levels of NT-proBNP were significantly lower in overweight or obese than in normal weight subjects (P<0.05). The relationship of obesity and decreased NT-proBNP levels persisted in subgroup of hypertension, both gender and both age levels (≥65 yrs and <65 yrs).Multivariate linear regression identified BMI as an independent negative correlate of LogNT-proBNP level. Conclusions An inverse relationship between BMI and plasma NT-proBNP concentrations have been demonstrated in AF patients without heart failure. Overweight or obese patients with AF appear to have lower NT-proBNP levels than normal weight patients.

Delayed efficacy of radiofrequency catheter ablation on ventricular arrhythmias originating from the left ventricular anterobasal wall

BACKGROUND Ventricular arrhythmias (VAs) originating from the left ventricular anterobasal wall (LV-ABW) may represent a therapeutic challenge. OBJECTIVE The purpose of this study was to investigate the delayed efficacy of radiofrequency catheter (RFCA) ablation without an epicardial approach on VAs originating from the LV-ABW. METHODS Eighty patients (mean age 46.9 ± 14.9 years; 47 male) with VAs originating from the LV-ABW were enrolled. After systematic mapping of the right ventricular outflow tract, aortic root, adjacent LV endocardium, and coronary venous system, 3-4 ablation attempts were made at the earliest activation sites and/or best pace-mapping sites. Delayed efficacy was evaluated in patients with acute failure. RESULTS During mean follow-up of 23.8 ± 21.9 months (range 3-72 months), complete elimination of all VAs was achieved in 47 patients (59%) and partial success in 19 (24%), for an overall success rate of 83%. In 25 of 37 patients (68%) with acute failure, VAs were eliminated or significantly reduced (>80% VA burden) by the delayed effect of RFCA during follow-up. Logistic regression analysis revealed that response time to ablation was a predictor of occurrence of delayed efficacy. No complications occurred during follow-up. CONCLUSION Instead of extensive ablation, waiting for delayed efficacy of RFCA may be a reasonable choice for patients with VAs arising from the LV-ABW.