Mahmut F. Güneş

Acute and early outcomes of focal impulse and rotor modulation (FIRM)-guided rotors-only ablation in patients with nonparoxysmal atrial fibrillation

BACKGROUND Focal impulse and rotor modulation (FIRM)-guided ablation targets sites that are thought to sustain atrial fibrillation (AF). OBJECTIVE The purpose of this study was to evaluate the acute and mid-term outcomes of FIRM-guided only ablation in patients with nonparoxysmal AF. METHODS We prospectively enrolled patients with persistent and long-standing persistent (LSP) AF at three centers to undergo FIRM-guided only ablation. We evaluated acute procedural success (defined as AF termination, organization, or ≥10% slowing), safety (incidence of periprocedural complications), and long-term success (single-procedure freedom from atrial tachycardia [AT]/AF off antiarrhythmic drugs [AAD] after a 2-month blanking period). RESULTS Twenty-nine patients with persistent (N = 20) and LSP (N = 9) AF underwent FIRM mapping. Rotors were presents in all patients, with a mean of 4 ± 1.2 per patient (62% were left atrial); 1 focal impulse was identified. All sources were successfully ablated, and overall acute success rate was 41% (0 AF termination, 2 AF slowing, 10 AF organization). There were no major procedure-related adverse events. After a mean 5.7 months of follow-up, single-procedure freedom from AT/AF without AADs was 17%. CONCLUSION In nonparoxysmal AF patients, targeted ablation of FIRM-identified rotors is not effective in obtaining AF termination, organization, or slowing during the procedure. After mid-term follow-up, the strategy of ablating FIRM-identified rotors alone did not prevent recurrence from AT/AF.

Pulmonary Vein Antrum Isolation in Patients With Paroxysmal Atrial Fibrillation More Than a Decade of Follow-Up

Background—We report the outcome of pulmonary vein (PV) antrum isolation in paroxysmal atrial fibrillation (AF) patients over more than a decade of follow-up. Methods and Results—A total of 513 paroxysmal AF patients (age 54±11 years, 73% males) undergoing catheter ablation at our institutions were included in this analysis. PV antrum isolation extended to the posterior wall between PVs plus empirical isolation of the superior vena cava was performed in all. Non-PV triggers were targeted during repeat procedure(s). Follow-up was performed quarterly for the first year and every 6 to 9 months thereafter. The outcome of this study was freedom from recurrent AF/atrial tachycardia. At 12 years, single-procedure arrhythmia-free survival was achieved in 58.7% of patients. Overall, the rate of recurrent arrhythmia (AF/atrial tachycardia) was 21% at 1 year, 11% between 1 and 3 years, 4% between 3 and 6 years, and 5.3% between 6 and 12 years. Repeat procedure was performed in 74% of patients. Reconnection in the PV antrum was found in 31% of patients after a single procedure and in no patients after 2 procedures. Non-PV triggers were found and targeted in all patients presenting with recurrent arrhythmia after ≥2 procedures. At 12 years, after multiple procedures, freedom from recurrent AF/atrial tachycardia was achieved in 87%. Conclusions—In patients with paroxysmal AF undergoing extended PV antrum isolation, the rate of late recurrence is lower than what previously reported with segmental or less extensive antral isolation. However, over more than a decade of follow-up, nearly 14% of patients developed recurrence because of new non-PV triggers.

Catheter ablation of inappropriate sinus tachycardia

Catheter ablation for inappropriate sinus tachycardia (IST) is recommended for patients symptomatic for palpitations and refractory to other treatments. The current approach consists in sinus node modification (SNM), achieved by ablation of the cranial part of the sinus node to eliminate faster sinus rates while trying to preserve chronotropic competence. This approach has a limited efficacy, with a very modest long-term clinical success. To overcome this, proper patient selection is crucial and an epicardial approach should always be considered. This brief review will discuss the current role and limitations of catheter ablation in the management of patients with IST.

How to Improve Cardiac Resynchronization Therapy Benefit in Atrial Fibrillation Patients: Pulmonary Vein Isolation (and Beyond).

Although cardiac resynchronization therapy (CRT) is an important treatment of symptomatic heart failure patients in sinus rhythm with low left ventricular ejection fraction and ventricular dyssynchrony, its role is not well defined in patients with atrial fibrillation (AF). CRT is not as effective in patients with AF because of inadequate biventricular capture and loss of atrioventricular synchrony. Both can be addressed with catheter ablation of AF. It is still unclear if these therapies offer additive benefits in patients with ventricular dyssynchrony. This article discusses the role and techniques of catheter ablation of AF in patients with heart failure, and its application in CRT recipients.

Reply : Factors Affecting Outcomes in Left Atrial Appendage Isolation by Catheter Ablation

We read with great interest the study conducted by Di Biase et al. (1) about the benefits of left atrial appendage isolation in patients with long-standing persistent atrial fibrillation undergoing catheter ablation. Although the study design was solid, it used left atrial diameter as a measurement of chamber size to compare both groups undergoing the randomization. Current research shows that left atrial volume index is a more precise measurement of the chamber size than atrial diameter (2,3). Thus, reporting the actual left atrial volume index for both groups could have represented a clear idea if this could be a confounding factor for the reported results. Another observation noted was the absence of amiodarone from antiarrhythmic medications reported at baseline characteristic, which may have contributed to the different recurrence risk in both groups. Moreover, designing multivariate regression models adjusted for age, sex, and left atrial size might have masked the actual hazard ratio if it was adjusted for the other multiple risk factors contributing to the atrial fibrillation recurrence, which included ejection fraction, hypertension, and atrial fibrillation symptom duration (4). We noticed that the methods used to follow-up for atrial fibrillation recurrence were more subjective. Using implantable cardiac monitors would have been more precise than patient-triggered event monitor or the intermittent use of Holter monitors that were used to detect atrial fibrillation recurrence. Finally, the study did not report any adverse events associated with either type of ablation procedure. Those who underwent the left atrial appendage isolation (group 1) were exposed to longer duration of radiofrequency (93.1 26.2 min) than those who underwent the standard ablation procedure (group 2; 77.4 29.9 min).

How to Improve Cardiac Resynchronization Therapy Benefit in Atrial Fibrillation Patients: Pulmonary Vein Isolation (and Beyond)

Although cardiac resynchronization therapy (CRT) is an important treatment of symptomatic heart failure patients in sinus rhythm with low left ventricular ejection fraction and ventricular dyssynchrony, its role is not well defined in patients with atrial fibrillation (AF). CRT is not as effective in patients with AF because of inadequate biventricular capture and loss of atrioventricular synchrony. Both can be addressed with catheter ablation of AF. It is still unclear if these therapies offer additive benefits in patients with ventricular dyssynchrony. This article discusses the role and techniques of catheter ablation of AF in patients with heart failure, and its application in CRT recipients.

USEFULNESS OF ULTRASOUND-GUIDED FEMORAL VEIN ACCESS IN ATRIAL FIBRILLATION ABLATION

Vascular complications remain the most common complication in percutaneous electrophysiological procedures and are associated with increased morbidity and health-care costs. We sought to evaluate the effect of real-time ultrasound (US) guidance for femoral vein access in atrial fibrillation ablation