Peter Lukac

Long-term outcome of ablative therapy of post-operative atrial tachyarrhythmias in patients with tetralogy of Fallot: A European multi-centre study

AIM Post-operative atrial tachyarrhythmias (AT) in patients with tetralogy of Fallot (ToF) are associated with congestive heart failure, stroke, and cardiac death. Effective treatment is therefore essential. The aim of the study is to evaluate long-term outcome of ablative therapy of AT in ToF patients and to study characteristics of AT recurrences. METHODS AND RESULTS Tetralogy of Fallot patients (N = 38, age 43 ± 12 years) referred for ablation of post-operative AT, appearing 26 ± 10 years after complete repair, were studied. Electro-anatomical/entrainment mapping was performed prior to ablation. Successful ablation was defined as (i) achievement of bi-directional conduction block for isthmus-dependent atrial flutter (IDAF), (ii) termination during ablation for intra-atrial reentrant tachycardia (IART) and focal atrial tachycardia (FAT). Fifty-two AT were ablated, including 37 IDAF [cycle length (CL) 294 ± 70 ms], 11 IART (CL 295 ± 46 ms), and 4 FAT (CL 371 ± 93 ms). Ablation was successful in 98%. Fifty-one of 52 AT involved the cavo-tricuspid isthmus and/or the area between scar tissue related to prior atriotomy incisions and the inferior caval vein. Multiple AT developed in 11 patients, with different mechanisms in 9. After 45 ± 24 months, 32 patients were in sinus rhythm; 5 used anti-arrhythmic drugs. CONCLUSION Ablative therapy of AT in ToF patients is an effective curative treatment modality with a high procedural success rate. Sinus rhythm during long-term follow-up was obtained in the majority of patients. Fifty-one of 52 AT originated from sites related to surgical incisions created at complete repair, suggesting that extending the atriotomy incision towards the inferior caval vein during cardiac surgery combined with surgical ablation of the cavo-tricuspid isthmus will be effective in preventing development of AT.

Long-term outcome of ablative therapy of postoperative supraventricular tachycardias in patients with univentricular heart: a European multicenter study.

Background—Catheter ablation has evolved as a possible curative treatment modality for supraventricular tachycardias (SVT) in patients with univentricular heart. However, the long-term outcome of ablation procedures is unknown. We evaluated the procedural and long-term outcome of ablative therapy of late postoperative SVT in patients with univentricular heart. Methods and Results—Patients with univentricular heart (n=19, 11 male; age, 29±9 years) referred for ablation of SVT were studied. Ablation was guided by 3D electroanatomic mapping in all but 2 procedures. A total of 41 SVT were diagnosed as intra-atrial reentrant tachycardia (n=30; cycle length, 310±68 ms), typical atrial flutter (n=4; cycle length, 288±42 ms), focal atrial tachycardia (n=6; cycle length, 400±60 ms), and atrial fibrillation (n=1). Ablation was successful in 73% of intra-atrial reentrant tachycardia, 75% of atrial flutter, and all focal atrial tachycardia and focal atrial fibrillation. During the follow-up period of 53±34 months, 2 patients were lost to follow-up, 3 died of heart failure, 2 underwent heart transplantation, and 1 underwent conduit replacement. Of the remaining group, 8 had sinus rhythm and 3 had SVT. Conclusions—Focal and reentrant mechanisms underlie postoperative SVT in patients with univentricular heart. Successive SVT developing over time may be caused by different mechanisms. Ablative therapy is potentially curative, with a procedural success rate of 78%. In patients who had multiple ablation procedures, the SVT originated from different atrial sites, suggesting that these new SVT were caused by progressive atrial disease. Despite recurrent SVT, sinus rhythm at the end of the follow-up period was achieved in 72%.

Radiofrequency ablation of accessory pathways in patients with the Wolff–Parkinson–White syndrome: the long-term mortality and risk of atrial fibrillation

AIMS To assess the long-term mortality and occurrence of post-ablation atrial fibrillation in patients undergoing a radiofrequency ablation for the Wolff-Parkinson-White (WPW) syndrome. METHODS AND RESULTS A retrospective cohort study of patients (N = 362) subjected to radiofrequency ablation of the WPW syndrome at Aarhus University Hospital from 1990 to 2011. A comparison cohort (N = 3619) was generated from the Danish National Board of Health Central Population Registry. We found no significant difference in all-cause mortality when comparing the WPW group with the control group [hazard ratio (HR): 0.77 and confidence interval (CI): 0.47-1.25]. After radiofrequency ablation, the WPW group had a significantly higher risk of atrial fibrillation than the control group (HR: 4.77 and CI: 3.05-7.43). Atrial fibrillation prior to ablation (HR: 4.66 and CI: 2.09-10.41) and age over 50 years (HR: 9.79 and CI: 4.29-22.36) at the time of ablation were independent risk factors for post-ablation atrial fibrillation in the WPW group. CONCLUSION Patients with radiofrequency ablation-treated WPW syndrome have a post-ablation mortality that is similar to the background population. The risk of atrial fibrillation remains high after radiofrequency ablation of the WPW syndrome.

The superior transseptal surgical approach to mitral valve creates slow conduction.

Background: Atrial tachycardia is very frequent after mitral valve surgery using the superior transseptal approach.

Ablation for idiopathic ventricular arrhythmia – with and without arrhythmia-induced cardiomyopathy

Abstract Objectives. We conducted a study to assess the procedural success and long-term freedom from arrhythmia in patients treated with radiofrequency ablation (RFA) for idiopathic ventricular arrhythmia (VA) with and without arrhythmia-induced cardiomyopathy (AIC). Design. We identified 131 patients treated with RFA for idiopathic VA in our institution; 16 of whom had AIC. Data were obtained from patient files. A questionnaire was used to assess the improvement in subjective symptoms late after RFA. Results. At the initial RFA, any VA was abolished in 93 patients (71%), non-targeted VA still was observed in 5 patients (4%), and the targeted VA remained present in 29 (22%). In 4 patients (3%) procedural success was undeterminable. During a median follow-up time of 8 months after latest RFA, 100 patients (76%) stayed free from recurrence. We observed no difference in procedural or long-term success between patients with and without AIC. When excluding patients with fascicular ventricular tachycardia (VT), a significantly higher proportion of patients with AIC had VA originating from the left ventricle (p = 0.027). Patients with AIC had a significant improvement of ejection fraction after RFA (p < 0.001). Totally 89 of 99 patients (90%) who returned the questionnaire reported symptomatic benefit a median of 64 months after their latest procedure. Conclusions. RFA is effective for treating idiopathic VA with and without AIC, with high rates of long-term freedom from VA and symptomatic relief. We found more patients with AIC had left ventricle VA.

Is the knowledge of contact force beneficial in pulmonary vein antrum isolation

Abstract Objective: To investigate the effect of the operator knowing the real-time contact force (CF) on the efficacy of pulmonary vein antrum isolation (PVAI). Methods: Fifty patients with paroxysmal atrial fibrillation (AF) or short lasting persistent AF were randomized to CF guided PVAI (n = 25) or conventional PVAI (n = 25). In the CF guided group, CF between 10 and 40 g was aimed at. Efficacy of PVAI was measured as reduction in AF burden (AFB) and time to AF recurrence detected by implantable cardiac monitor (ICM), inserted three months before PVAI. Blanking period was three months and follow-up 12 months. Results: All pulmonary veins were isolated in the CF guided group and all but one in the conventional group. Mean CF was 25 g in the CF guided group and 24 g in the conventional group (p = 0.75). Compared to pre-ablation, median [IQR] relative reduction in AFB 3–12 months after ablation was 100 [99–100]% in the CF guided group (p < 0.001) and 99.4 [25–100]% in the conventional group (p < 0.001), not different between groups (p = 0.09). Nine patients (36%) had AF recurrence in the CF guided group and 13 (52%) in the conventional group (p = 0.21, log-rank test). CF differed between operators. When adjusted for operator by regression analysis, patients without recurrent AF had lower proportion of ablation time with CF <10 g than recurrent patients (p = 0.034). No complications occurred. Conclusions: Operator knowledge of real-time CF had no significant effect on AFB reduction or time to AF recurrence. Larger trials should be done to study benefit of real-time CF.

Recurrence after pulmonary vein isolation is associated with low contact force

Abstract Objectives. Recurrent arrhythmia after pulmonary vein isolation (PVI) by radiofrequency (RF) ablation in patients with atrial fibrillation (AFIB) remains a significant challenge. Using contact force (CF) sensing ablation catheters, we aimed to identify procedure related parameters associated with recurrence after de-novo PVI in patients with AFIB. Methods. Consecutive patients undergoing a de-novo PVI procedure (n = 120, 63% paroxysmal and 37% persistent AFIB) employing a force-sensing ablation catheter were included. A clinical control including electrocardiogram and 120 hour of Holter-recording at 12-months was performed in all patients. Recurrence was defined as any documented AFIB or atrial flutter more than 30 seconds on Holter-recording after an initial blanking period of three months. Results. Recurrence occurred in 44 patients (37%). Mean CF was lower in patients with recurrent arrhythmia (22.2 ± 9.5 vs. 28.8 ± 9.3 g, p < .001). In multi-variable analyses lower mean CF (OR 0.9 (95% CI 0.8–1.0), p = .03), and higher percentage of ablation time with a CF <10 grams (OR 1.1 (95% CI 1.0–1.1), p = .004) were both associated with recurrence in two distinct models. Dragging during ablation compared with point-by-point ablation technique was associated with recurrence in both models (OR 19.2 (95% CI 2.9–130.0), p = .002, and OR 21.7 (95% CI 2.7–176.2), p = .004). Conclusions. Low CF and dragging during ablation as compared with point-by-point ablation technique were associated with recurrent arrhythmia in patients with AFIB undergoing de-novo PVI by RF ablation.

Catheter ablation for ventricular tachycardia in ischaemic heart disease; Acute success and long-term outcome

Abstract Objectives. We conducted a study to assess the acute procedural success and the long-term effect of radiofrequency ablation (RFA) for ventricular tachycardia (VT) in patients with ischaemic heart disease. Design. We included 90 patients with ischaemic heart disease treated with RFA for VT in our institution. Data were obtained from patient files, and implantable cardioverter-defibrillator (ICD) discharges were recorded from in-house and remote follow-up data. Recurrence of VT during follow-up was noted as date of first ICD therapy for VT or first recurrence of symptomatic VT. Results. After the initial RFA procedure no VT was inducible in 42 patients (47%), non-clinical VT was inducible in 21 patients (23%), and the clinical VT was still inducible in 14 patients (16%). The procedural success was indefinable in 13 patients (14%). After a median follow-up of 33 months after the latest RFA, 38 patients (42%) stayed free from recurrent VT. The number of ICD shocks/year was significantly reduced from median 1.1 (interquartile range: 0.3–2.8) to 0 (0–0.4) (p < 0.0001). Conclusions. Procedural success rate as well as long-term freedom from recurrent VT is modest after RFA for VT in ischaemic heart disease. However, ICD discharges are significantly reduced after RFA, and a considerable proportion of patients remain free from recurrent VT during the long-term follow-up.

Long-Term Outcome of Ablative Therapy of Postoperative Supraventricular Tachycardias in Patients With Univentricular HeartCLINICAL PERSPECTIVE

Background—Catheter ablation has evolved as a possible curative treatment modality for supraventricular tachycardias (SVT) in patients with univentricular heart. However, the long-term outcome of ablation procedures is unknown. We evaluated the procedural and long-term outcome of ablative therapy of late postoperative SVT in patients with univentricular heart. Methods and Results—Patients with univentricular heart (n=19, 11 male; age, 29±9 years) referred for ablation of SVT were studied. Ablation was guided by 3D electroanatomic mapping in all but 2 procedures. A total of 41 SVT were diagnosed as intra-atrial reentrant tachycardia (n=30; cycle length, 310±68 ms), typical atrial flutter (n=4; cycle length, 288±42 ms), focal atrial tachycardia (n=6; cycle length, 400±60 ms), and atrial fibrillation (n=1). Ablation was successful in 73% of intra-atrial reentrant tachycardia, 75% of atrial flutter, and all focal atrial tachycardia and focal atrial fibrillation. During the follow-up period of 53±34 months, 2 patients were lost to follow-up, 3 died of heart failure, 2 underwent heart transplantation, and 1 underwent conduit replacement. Of the remaining group, 8 had sinus rhythm and 3 had SVT. Conclusions—Focal and reentrant mechanisms underlie postoperative SVT in patients with univentricular heart. Successive SVT developing over time may be caused by different mechanisms. Ablative therapy is potentially curative, with a procedural success rate of 78%. In patients who had multiple ablation procedures, the SVT originated from different atrial sites, suggesting that these new SVT were caused by progressive atrial disease. Despite recurrent SVT, sinus rhythm at the end of the follow-up period was achieved in 72%.

Long-Term Outcome of Ablative Therapy of Postoperative Supraventricular Tachycardias in Patients With Univentricular HeartCLINICAL PERSPECTIVE: A European Multicenter Study

Background—Catheter ablation has evolved as a possible curative treatment modality for supraventricular tachycardias (SVT) in patients with univentricular heart. However, the long-term outcome of ablation procedures is unknown. We evaluated the procedural and long-term outcome of ablative therapy of late postoperative SVT in patients with univentricular heart. Methods and Results—Patients with univentricular heart (n=19, 11 male; age, 29±9 years) referred for ablation of SVT were studied. Ablation was guided by 3D electroanatomic mapping in all but 2 procedures. A total of 41 SVT were diagnosed as intra-atrial reentrant tachycardia (n=30; cycle length, 310±68 ms), typical atrial flutter (n=4; cycle length, 288±42 ms), focal atrial tachycardia (n=6; cycle length, 400±60 ms), and atrial fibrillation (n=1). Ablation was successful in 73% of intra-atrial reentrant tachycardia, 75% of atrial flutter, and all focal atrial tachycardia and focal atrial fibrillation. During the follow-up period of 53±34 months, 2 patients were lost to follow-up, 3 died of heart failure, 2 underwent heart transplantation, and 1 underwent conduit replacement. Of the remaining group, 8 had sinus rhythm and 3 had SVT. Conclusions—Focal and reentrant mechanisms underlie postoperative SVT in patients with univentricular heart. Successive SVT developing over time may be caused by different mechanisms. Ablative therapy is potentially curative, with a procedural success rate of 78%. In patients who had multiple ablation procedures, the SVT originated from different atrial sites, suggesting that these new SVT were caused by progressive atrial disease. Despite recurrent SVT, sinus rhythm at the end of the follow-up period was achieved in 72%.