Takehito Sasaki

Silent Cerebral Ischemic Lesions After Catheter Ablation of Atrial Fibrillation in Patients on 5 Types of Periprocedural Oral Anticoagulation - Predictors of Diffusion-Weighted Imaging-Positive Lesions and Follow-up Magnetic Resonance Imaging.

BACKGROUND The aim of this study was to identify the predictors of silent cerebral ischemic lesions (SCIL) after catheter ablation of atrial fibrillation (AF) and to determine whether SCIL develop into cerebral infarcts in patients with 5 types of oral anticoagulants (OAC). METHODSANDRESULTS We retrospectively studied 286 consecutive patients (median, 67 years; 208 male; paroxysmal/persistent/long-standing persistent AF [LSP-AF], 147/90/49) who received periprocedural OAC and underwent MRI after the procedure. Warfarin (n=46) was continued, while dabigatran (n=47), rivaroxaban (n=89), apixaban (n=87), and edoxaban (n=17) were discontinued on the day of the procedure. I.v. heparin was infused to maintain an activated clotting time of 300-350 s during the procedure. Fifty-eight SCIL in 40 patients (14.0%) were identified on diffusion-weighted MRI. On multivariate logistic analysis, LSP-AF and dabigatran use were significant positive predictors of SCIL (OR, 2.912 and 2.287; P=0.006 and 0.042, respectively). Among 34 patients with 49 SCIL undergoing follow-up MRI, 45 (91.8%) of the lesions disappeared and 4 lesions developed into chronic cerebral infarcts. The SCIL with development into infarcts had a larger lesion diameter than those without (median, 6.55 mm vs. 4.2 mm; P=0.002). CONCLUSIONS LSP-AF and dabigatran use were independent risk factors for post-ablation SCIL in patients with uninterrupted warfarin and interrupted non-vitamin K antagonist OAC, but the majority of SCIL disappeared.

Optimal observation time after completion of circumferential pulmonary vein isolation for atrial fibrillation to prevent chronic pulmonary vein reconnections

PURPOSE To identify predictors of chronic pulmonary vein (PV) reconnection (CPVR) after successful circumferential PV isolation (CPVI) for atrial fibrillation (AF). MATERIALS AND METHODS A total of 718 PVs from 181 consecutive AF patients (141 males, median age 61 years, 92 paroxysmal AF) who underwent a second ablation procedure for recurrent AF were retrospectively analyzed. RESULTS During the second procedure, a CPVR was observed in 477 PVs (66.4%) among 169 patients. In a multiple logistic regression analysis, the observation time after the final completion of the PVI (OT-final) was a significant negative predictor (odds ratio 0.980; P<0.001). A receiver operating characteristic analysis demonstrated that the greatest area under the curve was for the OT-final (0.670). At an optimal cutoff of 35 min, the sensitivity and specificity for predicting a CPVR were 66.9% and 60.6%, respectively. By Kaplan Meier analysis, CPVR was more frequent in PVs with an OT-final of <35 min than ≥35 min (log-rank test, P=0.018). In a vessel-by-vessel analysis, the OT-final at all PV sites was a significant negative predictor, while male gender in the right PVs and left-inferior PV, number of RF applications for the ipsilateral CPVI in the right PVs and left-superior PV, and major PV diameter in the left-superior PV were significant positive predictors of a CPVR (all P<0.05). CONCLUSIONS An optimal observation time (≥35 min in this study) to determine whether PVI is successfully completed during the initial CPVI for AF may be needed to prevent a CPVR and subsequent AF recurrence thereafter.

Inferior Vena Cava Compression as a Novel Maneuver to Detect Patent Foramen Ovale: A Transesophageal Echocardiographic Study

Background: The Valsalva maneuver, the most sensitive test for patent foramen ovale (PFO) detection, is difficult during transesophageal echocardiography (TEE), especially after sedation. The aim of this study was to compare PFO detection effectiveness between inferior vena cava (IVC) compression and the Valsalva maneuver. Methods: A total of 293 patients with paroxysmal atrial fibrillation undergoing TEE before initial atrial fibrillation ablation were prospectively enrolled. Agitated saline was injected in 290 patients under three conditions: Valsalva maneuver under conscious sedation, at rest, and IVC compression under deep sedation. Three patients with newly diagnosed atrial septal defects on TEE were excluded. The IVC compression maneuver consisted of manual compression 5 cm to the right of the epigastric region and depressed the abdominal wall by 5 cm for 30 sec and compression release immediately before right atrial opacification with microbubbles by agitated intravenous saline. Results: The overall PFO detection rate was better with IVC compression (57 PFOs [19.7%]) than at rest (15 patients [5.2%]) (P < .0001) or with the Valsalva maneuver (37 patients [12.8%]) (P = .024). There were no significant differences in PFO detection between IVC compression and the Valsalva maneuver (IVC compression, 43 patients [22.5%]; Valsalva maneuver, 35 patients [18.3%]; P = .31), even in patients who could perform the Valsalva maneuver effectively (n = 191). Conclusions: IVC compression is feasible and effective for detecting PFO and is not inferior to the Valsalva maneuver. In particular, IVC compression could be an alternative diagnostic method for PFO using TEE when the Valsalva maneuver cannot be performed under deep sedation. HighlightsThe authors propose IVC compression as new provocation maneuver to detect PFO.IVC compression is feasible and not inferior to the Valsalva maneuver.IVC compression should be performed when the Valsalva maneuver is not effective.

Accessory pathway location affects brain natriuretic peptide level in patients with Wolff–Parkinson–White syndrome

PurposeThe purpose of this study was to investigate the relationship between the accessory pathway location and brain natriuretic peptide (BNP) level in patients with Wolff–Parkinson–White (WPW) syndrome.MethodsWe divided 102 WPW syndrome patients with normal left ventricular systolic function into four groups: those with manifest right (MR, n = 14), manifest septal (MS, n = 11), manifest left (ML, n = 30), and concealed (C, n = 47) accessory pathways. BNP level and electrophysiological properties, including difference in timing of the ventricular electrogram between the His bundle area and the distal coronary sinus area (His–CS delay), which indicate intraventricular dyssynchrony, were compared.ResultsBNP levels (pg/dl) were higher in the MR and MS groups than in the ML and C groups (MR, 64 ± 58; MS, 55 ± 45; ML, 17 ± 15; C, 25 ± 21; P < 0.001). AV intervals (ms) were shorter in the MR and MS groups than in the ML and C groups (MR, 76 ± 16; MS, 83 ± 6; ML, 101 ± 19; C, 136 ± 20; P < 0.001). His–CS delay (ms) was longer in the MR group than in the other groups (MR, 50 ± 15; MS, 21 ± 7; ML, 23 ± 10; C, 19 ± 8; P < 0.001). The AV interval (P < 0.01) and the His–CS delay (P < 0.001) were negatively and positively correlated, respectively, with the BNP level.ConclusionAnterograde conduction with a right or septal accessory pathway increased the BNP level in WPW syndrome patients with normal cardiac function.

Integration of intracardiac echocardiography and computed tomography during atrial fibrillation ablation: Combining ultrasound contours obtained from the right atrium and ventricular outflow tract

BACKGROUND We aimed to optimize the acquisition of the left atrial (LA) and pulmonary vein (PV) ultrasound contours for more accurate integration of intracardiac echocardiography (ICE) and computed tomography (CT) using the CARTO® 3 system during atrial fibrillation (AF) ablation. METHODS Eighty-five AF patients underwent integration of ICE and CT using (1) the LA roof and posterior wall contours acquired from the right atrium (RA), (2) all LA/PV contours from the RA (Whole-RA-integration), (3) the LA roof/posterior wall contours from the RA and right ventricular outflow tract (RVOT) (Posterior-RA/RV-integration), and (4) all LA/PV contours from the RA and RVOT (Whole-RA/RV-integration). The integration accuracy was compared using the (1) surface registration error, (2) distances between the three-dimensional CT and eight specific sites on the anterior, posterior, superior, and inferior aspects of the right and left circumferential PV isolation lines, and (3) registration score: a score of 0 or 1 was assigned for whether or not each specific site was visually aligned with the CT, and summed for each method (0 best, 8 worst). RESULTS Posterior-RA/RV-integration revealed a significantly lower surface registration error (1.30±0.15mm) than Whole-RA- and Whole-RA/RV-integration (p<0.001). The mean distances of the eight specific sites and the registration score for Posterior-RA/RV-integration (median 1.26mm and 2, respectively) were significantly smaller than those for the other integration approaches (p<0.001). CONCLUSIONS Image integration with the LA roof and posterior wall contours acquired from the RA and RVOT may provide greater accuracy for catheter navigation with three-dimensional CT during AF ablation.

Successful Ablation of Cavotricuspid Isthmus-dependent Atrial Flutter Guided by Contact Force Vector in a Patient After a Tricuspid Valve Replacement

A 46-year-old man after a tricuspid valve replacement due to traumatic severe tricuspid regurgitation developed cavotricuspid isthmus-dependent counterclockwise atrial flutter. During a linear ablation using a contact force-sensing irrigated ablation catheter, the flutter could be terminated by a radiofrequency application within a deep pouch just below the bioprosthetic tricuspid valve.

Post-ablation Cerebral Embolisms in Balloon-based Atrial Fibrillation Ablation with Periprocedural Direct Oral Anticoagulants: a Comparison between Cryoballoon and HotBalloon Ablation: NAKAMURA et al.

This prospective observational study aimed to investigate the incidence of symptomatic and silent cerebral embolisms after balloon‐based ablation of atrial fibrillation (AF) in patients receiving periprocedural anticoagulation with direct oral anticoagulants (DOACs), and compare that between cryoballoon and HotBalloon ablation (CBA and HBA).

Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective randomized single-centre study on post-ablation thrombo-embolic and haemorrhagic events

Aims This prospective, randomized, single-centre study aimed to directly compare the safety and efficacy of uninterrupted and interrupted periprocedural anticoagulation protocols with direct oral anticoagulants (DOACs) in patients undergoing catheter ablation of non-valvular atrial fibrillation (NVAF). Methods and results We randomly assigned 846 NVAF patients receiving DOACs prior to ablation to uninterruption (n = 422) or interruption (n = 424) of the DOACs on the day of the procedure. The primary endpoint was a composite of symptomatic thromboembolisms and major bleeding events within 30 days after the ablation. Secondary endpoints included symptomatic and silent thromboembolisms and major and minor bleeding events. The primary endpoint occurred in 0.7% of the uninterrupted DOAC group [1 transient ischaemic attack (TIA) and 2 major bleeding events] and 1.2% of the interrupted DOAC group (1 TIA and 4 major bleeding events) (P = 0.480). The incidence of major and minor bleeding was comparable between the two groups (0.5% vs. 0.9%, P = 0.345; 5.9% vs. 5.4%, P = 0.753). Silent cerebral ischaemic lesions (SCILs) were observed in 138 (20.9%) of the 661 patients undergoing post-ablation magnetic resonance (MR) imaging. The uninterrupted and interrupted DOAC groups revealed a similar incidence of SCILs (19.8% vs. 22.0%, P = 0.484) and percentage of SCILs with disappearance on follow-up MR imaging (77.8% vs. 82.1%, P = 0.428). Conclusion Both the uninterrupted and interrupted DOAC protocols revealed a low risk of symptomatic thromboembolisms and major bleeding events and similar incidence of SCILs and minor bleeding events and may be feasible for periprocedural anticoagulation in NVAF patients undergoing catheter ablation.

A potential pitfall of the modified 12 lead electrocardiogram (Mason–Likar modification) in catheter ablation of idiopathic ventricular arrhythmias originating from the outflow tract

AIMS The Mason-Likar modified electrocardiogram (ML-ECG) can be interchanged with standard 12 lead ECG electrode positions (standard ECG) without affecting the diagnostic interpretation during sinus rhythm, but the morphological differences during ventricular arrhythmias have not been sufficiently evaluated. This study aimed to elucidate the morphological changes in the ML-ECG precordial leads. METHODS AND RESULTS In 53 consecutive patients with premature ventricular contractions predicted to originate from the outflow tract (OT-PVCs), the arrhythmias were analysed by those two ECG methods. The OT-PVC origin sites, which were predicted by currently published criteria with the respective ECG methods prior to catheter ablation, were compared with the successful ablation sites. Compared with the standard-ECG, S-waves in the ML-ECG became shallower in leads V1-4 (P < 0.05 in lead V1; P < 0.001 in leads V2-4), and pseudo-R-waves in lead V1 appeared in seven patients. The precordial leads transition zone shifted counter-clockwise in 18 patients in the ML-ECG. In leads I and aVL, the negative deflection amplitudes of the ML-ECG were greater than those of the standard ECG (P < 0.001), and polarity reversals in lead I appeared in 18 patients. The R-wave amplitudes in all ML-ECG inferior leads were greater than those in the standard-ECG leads (all for P < 0.001). Those changes had an effect on the diagnostic indexes for the localization, and the specificity of the criteria for the ML-ECG was poorer than that for the standard-ECG. CONCLUSION Great differences were found between those two ECG methods. Predicting OT-PVC origins by diagnostic criteria with the ML-ECG might result in a misdiagnosis and inefficient ablation.