Luis Aguinaga

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation

During the past three decades, catheter and surgical ablation of atrial fibrillation (AF) have evolved from investigational procedures to their current role as effective treatment options for patients with AF. Surgical ablation of AF, using either standard, minimally invasive, or hybrid techniques, is available in most major hospitals throughout the world. Catheter ablation of AF is even more widely available, and is now the most commonly performed catheter ablation procedure. In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Cardiac Arrhythmia Society (ECAS).1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC). This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.2 The rate of advancement in the tools, techniques, and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms, outcomes, and treatment of AF. For this reason, the HRS initiated an effort to rewrite and update this Consensus Statement. Reflecting both the worldwide importance of AF, as well as the worldwide performance of AF ablation, this document is the result of a joint partnership between the HRS, EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia [SOLAECE]). The purpose of this 2017 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 writing group, convened by these five international societies. The writing group is charged with defining the indications, techniques, and outcomes of AF ablation procedures. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including definitions relevant to this topic. The writing group is composed of 60 experts representing 11 organizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC, American Heart Association (AHA), Canadian Heart Rhythm Society (CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardiacas [SOBRAC]). All the members of the writing group, as well as peer reviewers of the document, have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest. All author and peer reviewer disclosure information is provided in Appendix A and Appendix B. In writing a consensus document, it is recognized that consensus does not mean that there was complete agreement among all the writing group members. Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation. These recommendations were systematically balloted by the 60 writing group members and were approved by a minimum of 80% of these members. The recommendations were also subject to a 1-month public comment period. Each partnering and collaborating organization then officially reviewed, commented on, edited, and endorsed the final document and recommendations. The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.3,4 It is important to state, however, that this document is not a guideline. The indications for catheter and surgical ablation of AF, as well as recommendations for procedure performance, are presented with a Class and Level of Evidence (LOE) to be consistent with what the reader is familiar with seeing in guideline statements. A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended. The writing group reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high-quality evidence from more than one randomized clinical trial, meta-analyses of high-quality randomized clinical trials, or one or more randomized clinical trials corroborated by high-quality registry studies. The writing group ranked available evidence as Level B-R when there was moderate-quality evidence from one or more randomized clinical trials, or meta-analyses of moderate-quality randomized clinical trials. Level B-NR was used to denote moderate-quality evidence from one or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies. This designation was also used to denote moderate-quality evidence from meta-analyses of such studies. Evidence was ranked as Level C-LD when the primary source of the recommendation was randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies of human subjects. Level C-EO was defined as expert opinion based on the clinical experience of the writing group. Despite a large number of authors, the participation of several societies and professional organizations, and the attempts of the group to reflect the current knowledge in the field adequately, this document is not intended as a guideline. Rather, the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.5,6 This consensus document is specifically focused on catheter and surgical ablation of AF, and summarizes the opinion of the writing group 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 caring for patients who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF, and those involved in research in the field of AF ablation. This statement is not intended to recommend or promote catheter or surgical ablation of AF. Rather, the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient. The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF. A second major objective is to provide recommendations for designing clinical trials and reporting outcomes of clinical trials of AF ablation. It is recognized that this field continues to evolve rapidly. As this document was being prepared, further clinical trials of catheter and surgical ablation of AF were under way.

Coronary artery revascularization in patients with sustained ventricular arrhythmias in the chronic phase of a myocardial infarction : Effects on the electrophysiologic substrate and outcome

OBJECTIVES The objective of this study was to analyze the influence of coronary artery revascularization in patients with ventricular arrhythmias. BACKGROUND Coronary artery revascularization is an effective treatment for myocardial ischemia; however, its effect on ventricular arrhythmias not related to an acute ischemic event has not been carefully studied. METHODS Sixty-four patients (58 men, mean age 65 +/- 8 years old) with prior myocardial infarction, spontaneous ventricular arrhythmias not related to an acute ischemic event (55 ventricular tachycardia, 9 ventricular fibrillation) and coronary lesions requiring revascularization were studied prospectively. Electrophysiological study was performed before and after revascularization, and events during follow-up were analyzed. RESULTS At initial study 61 patients were inducible into sustained ventricular arrhythmias. After revascularization, in 62 survivors, 52 out of 59 patients previously inducible were still inducible (group A), and 10 patients were noninducible (group B). No differences were found in clinical, hemodynamic, therapeutic and electrophysiological characteristics between both groups. During 32 +/- 26 months follow-up, 28/52 patients in group A (54%) and 4/10 patients in group B (40%) had arrhythmic events (p = 0.46). An ejection fraction <30% predicted recurrent arrhythmic events (p = 0.02), but not the presence of demonstrable ischemia before revascularization (p = 0.42), amiodarone (p = 0.69) or beta-adrenergic blocking agent therapy (p = 0.53). Total mortality was 10% in both groups. CONCLUSIONS In patients with ventricular arrhythmias in the chronic phase of myocardial infarction, probability of recurrence is high despite coronary artery revascularization, but mortality is low if combined with appropriate antiarrhythmic therapy. Recurrences are related to the presence of a low ejection fraction but not to demonstrable ischemia before revascularization, amiodarone or beta-blocker therapy nor are they the results of electrophysiological testing after revascularization.

Long-Term Follow-Up in Patients with the Permanent Form of Junctional Reciprocating Tachycardia Treated with Radiofrequency Ablation

This study sought to determine the long‐term follow‐up, safety, and efficacy of radiofrequency catheter ablation of patients with the permanent form of junctional reciprocating tachycardia (PJRT). We assessed the reversibility of tachycardia induced LV dysfunction and we detailed the location and electrophysiological characteristics of these retrograde atrioventricular decremental pathways. PJRT is an infrequent form of reciprocating tachycardia, commonly incessant, and usually drug refractory. The ECG hallmarks include an RP interval > PR with inverted P waves in leads II, III, aVF, and V3‐V6. During tachycardia, retrograde VA conduction occurs over an accessory pathway with slow and decremental conduction properties, located predominantly in the posteroseptal zone. It is known that long‐lasting and incessant tachycardia may result in tachycardia induced severe ventricular dysfunction. We included 36 patients (13 men, 23 women, mean ± SD, aged 44 ± 22 years) with the diagnosis of PJRT. Seven patients had tachycardia induced left ventricular dysfunction. Radiofrequency energy was delivered at the site of earliest retrograde atrial activation during ventricular pacing or during reciprocating tachycardia. All patients were followed at the outpatient clinic and serial echocardiograms were performed in those who presented with depressed LV function. Radiofrequency ablation was performed in 36 decremental accessory pathways. Earliest retrograde atrial activation was righ t posteroseptal in 32 patients (88%), right mid‐septal in 2 (6%), right posteroiateral in 1 (3%), and left anterolateral in 1 (3%). Thirty‐five accessory pathways were successfully ablated with a mean of 5 ± 3 applications. A mid‐septal accessory pathway could not be ablated. After a mean follow‐up of 21 ± 16 months (range 1–64) 34 patients are asymptomatic. There were recurrences in 8 patients after the initial successful ablation (mean of 1.2 months), 5 were ablated in a second ablation procedure, 2 patients required a third procedure, and 1 patient required four ablation sessions. All patients with LV dysfunction experienced a remarkable improvement after ablation. Mean preablation LV ejection fraction in patients with tachycardiomyopathy was 28%± 6% and rose to 51%± 16% after ablation (P < 0.02). Our study supports the concept that radiofrequency catheter ablation is a safe and effective treatment for patients with PJRT. Radiofrequency ablation should be the treatment of choice in these patients because this arrhythmia is usually drug refractory. The majority of accessory pathways are located in the posteroseptal zone. Cessation of the arrhythmia after successful ablation results in recovery of LV dysfunction.

Neurohormonal, structural, and functional recovery pattern after premature ventricular complex ablation is independent of structural heart disease status in patients with depressed left ventricular ejection fraction: a prospective multicenter study.

OBJECTIVES This study aimed to assess the benefit after ablation of premature ventricular complexes (PVC) in patients with frequent PVC and left ventricular (LV) dysfunction, regardless of previous structural heart disease (SHD) diagnosis, PVC morphology, or estimated site of origin. BACKGROUND Ablation of PVC in patients with LV dysfunction is usually restricted to patients with suspected PVC-induced cardiomyopathy. METHODS Consecutive patients with frequent PVC and LV dysfunction accepted for ablation at 4 centers were prospectively included. Of the 80 patients included, 27 (34%) had a diagnosis of SHD. RESULTS Successful sustained ablation (SSA) was achieved in 53 (66%) patients, and LVEF improved in these patients from 33.7 ± 8% to 43.8 ± 9.4% and 45.8 ± 10.9% at 6 and 12 months, respectively (p < 0.05), without differences related to previous diagnosis of SHD (p = 0.69). BNP decreased from 109 [64 to 242] pg/ml to 60 [25 to 170] pg/ml, 50 [14 to 130] pg/ml, and 60 [19 to 81] pg/ml at 1, 6, and 12 months (p < 0.05). Patients in NYHA class I increased from 12 (23%) to 42 (79%) at 12 months (p < 0.05). A 13% baseline PVC burden had 100% sensitivity and 85% specificity to predict an absolute increase ≥ 5% in LVEF after SSA. Although 20 patients with >13% PVC and SSA had class I indication for cardioverter defibrillator implantation, these indications were absent at 6 months post-ablation. CONCLUSIONS Independently of the presence of SHD, the SSA of frequent PVC in patients with depressed LVEF induced a progressive clinical and functional improvement. Improvement in heart failure parameters was related to baseline PVC burden and persistence of ablation success.

Arrhythmia recurrence in patients with a healed myocardial infarction who received an implantable defibrillator: analysis according to the clinical presentation

OBJECTIVES The purpose of this study was to analyze the type of arrhythmia recurrence, based on stored electrograms, in patients with a healed myocardial infarction (MI) who received an implantable defibrillator. BACKGROUND Previous studies suggest that patients presenting with cardiac arrest (CA) tend to recur as ventricular fibrillation (VF), whereas those suffering sustained monomorphic ventricular tachycardia (SMVT) tend to recur as SMVT. However, these data have not been confirmed in a homogeneous population of patients with MI. METHODS A total of 88 patients was divided into three groups according to their clinical presentation: SMVT (n = 57), CA (n = 16) or syncope (n = 15). RESULTS There were no significant differences in clinical characteristics among groups. In the electrophysiologic study SMVT was induced in 93%, 94% and 80% of patients, respectively (p = NS). During the follow-up period, 52% of patients presented a total of 671 episodes of ventricular arrhythmia treated by the defibrillator. All recurrences were as SMVT except for one VF. There were 610 episodes of SMVT treated with antitachycardia pacing, with an effectiveness of 96%. A total of 61 episodes was treated initially with cardioversion. No differences in the probability of recurrence were observed among groups, although the statistical power was low (50%). CONCLUSIONS In patients with an old infarction and malignant ventricular arrhythmias, the majority of recurrences are due to SMVT independently of the clinical presentation (SMVT, CA or syncope) or the induced arrhythmia at the electrophysiologic study. The programming of an antitachycardia zone seems to be appropriate also for patients who present with CA or syncope.

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary

Hugh Calkins & Gerhard Hindricks & Riccardo Cappato & Young-Hoon Kim & Eduardo B. Saad & Luis Aguinaga & Joseph G. Akar & Vinay Badhwar & Josep Brugada & John Camm & Peng-Sheng Chen & Shih-Ann Chen & Mina K. Chung & Jens Cosedis Nielsen & Anne B. Curtis & D. Wyn Davies & John D. Day & André d’Avila & N.M.S. (Natasja) de Groot & Luigi Di Biase & Mattias Duytschaever & James R. Edgerton & Kenneth A. Ellenbogen & Patrick T. Ellinor & Sabine Ernst & Guilherme Fenelon & Edward P. Gerstenfeld & David E. Haines & Michel Haissaguerre & Robert H. Helm & Elaine Hylek & Warren M. Jackman & Jose Jalife & Jonathan M. Kalman & Josef Kautzner &Hans Kottkamp &Karl Heinz Kuck &Koichiro Kumagai &Richard Lee & Thorsten Lewalter & Bruce D. Lindsay & Laurent Macle & Moussa Mansour & Francis E. Marchlinski & Gregory F. Michaud & Hiroshi Nakagawa & Andrea Natale & Stanley Nattel & Ken Okumura & Douglas Packer & Evgeny Pokushalov & Matthew R. Reynolds & Prashanthan Sanders & Mauricio Scanavacca & Richard Schilling &Claudio Tondo &Hsuan-Ming Tsao &Atul Verma &David J.Wilber & Teiichi Yamane

Deterioro hemodinámico en pacientes sometidos a ablación del nodo auriculoventricular

Introduccion La ablacion con radiofrecuencia del nodo auriculoventricular ha emergido como una alternativa valida en el tratamiento de la fibrilacion auricular refractaria al tratamiento antiarritmico, habiendose demostrado ampliamente sus efectos beneficiosos. Hemos tratado a un subgrupo de pacientes que presentaron un deterioro hemodinamico despues de la ablacion, en relacion con un aumento del grado de insuficiencia mitral. Pacientes y metodos Hemos evaluado a 256 pacientes consecutivos remitidos para ablacion del nodo auriculoventricular e implantacion de marcapasos definitivo por fibrilacion auricular refractaria. Dado que observamos que el deterioro hemodinamico se dio solamente en pacientes con insuficiencia mitral previa a la ablacion comparamos retrospectivamente las caracteristicas clinicas, electrofisiologicas y ecocardiograficas de los pacientes con insuficiencia mitral previa y deterioro hemodinamico (grupo A, n = 14) y los pacientes sin deterioro hemodinamico (grupo B, n = 11). Resultados La duracion del procedimiento, la tecnica y el numero de aplicaciones durante la ablacion fueron similares en ambos grupos. El grado de insuficiencia mitral valorado de 1 (minima) a 4 (severa) era similar en ambos grupos antes de la ablacion (1,15 ± 1,05 frente a 1,11 ± 0,97). Los pacientes del grupo A presentaron un deterioro hemodinamico en forma de edema agudo de pulmon (3 pacientes) o insuficiencia cardiaca congestiva (11 pacientes) una media de 6 semanas despues de la ablacion. En todos ellos se aprecio un empeoramiento del grado de insuficiencia mitral (1,15 ± 1,05 frente a 2,90 ± 1,15; p Conclusion La ablacion con radiofrecuencia del nodo auriculoventricular junto a la implantacion de un marcapasos se acompana generalmente de una mejoria clinica notable; sin embargo, en un subgrupo de pacientes esta provoca un deterioro hemodinamico con empeoramiento de una insuficiencia mitral previa.

Predictors of All-Cause 1-Year Mortality in Implantable Cardioverter Defibrillator Patients with Chronic Chagas’ Cardiomyopathy

Background: Implantable cardioverter defibrillators (ICDs) have been used in the treatment of either sustained ventricular tachycardia or ventricular fibrillation in patients with Chagas’ cardiomyopathy. This study aimed at determining mortality rate and risk factors of all‐cause 1‐year mortality in primary and secondary ICD patients with Chagas’ cardiomyopathy.

Ablation of frequent PVC in patients meeting criteria for primary prevention ICD implant: Safety of withholding the implant

BACKGROUND Premature ventricular complex (PVC) ablation has been shown to improve left ventricular ejection fraction (LVEF) and New York Heart Association functional class in patients with left ventricular dysfunction. Both are considered key variables in predicting risk of sudden cardiac death. OBJECTIVE The objective of this study was to assess whether ablation might remove the primary prevention (PP) implantable cardioverter-defibrillator (ICD) indication in patients with frequent PVC. METHODS Sixty-six consecutive patients with PP-ICD indication and frequent PVC [33 (50%) men; mean age 53 ± 13 years; 11 (17%) with ischemic heart disease] underwent PVC ablation. The ICD was withheld and the indication was reevaluated at 6 and 12 months. RESULTS LVEF progressively improved from 28% ± 4% at baseline to 42% ± 12% at 12 months (P < .001). New York Heart Association functional class improved from 2 patients with NYHA functional class I (3%) at baseline to 35 (53%) at 12 months (P < .001). The brain natriuretic peptide level decreased from 246 ± 187 to 176 ± 380 pg/mL (P = .004). The PP-ICD indication was removed in 42 patients (64%) during follow-up, from 38 (92%) of them at 6 months, showing an independent association with baseline PVC burden and successful sustained ablation. In patients with successful sustained ablation, a cutoff value of 13% PVC burden had a sensitivity of 100% and a specificity of 93% (area under the curve 99%) for removing ICD indication postablation. No sudden cardiac deaths or malignant ventricular arrhythmias were observed. CONCLUSION In patients with frequent PVC and PP-ICD indication, ablation improves LVEF and, in most cases, allows removal of the indication. Withholding the ICD and reevaluating within 6 months of ablation seems to be a safe and appropriate strategy.

Pacientes con cardiopatía estructural, síncope de etiología desconocida y arritmias ventriculares inducibles tratados con desfibrilador implantable

Objetivos. Este estudio evalua la hipotesis que en pacientes con sincope de origen no conocido y anomalias cardiacas, las arritmias ventriculares inducibles son arritmias especificas y, por tanto, podrian ser tratadas apropiadamente. Antecedentes. El sincope es una entidad clinica frecuente. La evolucion y tratamiento de pacientes con sincope y anomalias cardiacas sin una clara etiologia no han sido bien definidos. Muchos pacientes tienen en su evaluacion un estudio electrofisiologico. En estas evaluaciones se encuentran anormalidades del nodo sinusal, prolongacion de los tiempos de conduccion o arritmias inducibles y, usualmente, se asume que esta es la causa del sincope y, segun ello, estos pacientes son tratados. Sin embargo, que las taquiarritmias sean la verdadera causa del sincope y que el tratamiento de estas taquiarritmias puede prevenir la recurrencia del sin