Veronika Bulková

Left atrial voltage during atrial fibrillation in paroxysmal and persistent atrial fibrillation patients

Background: Left atrial (LA) endocardial voltage characteristics assessed during atrial fibrillation (AF) have not been previously compared in different AF types. This study was aimed at investigating the LA voltages and volumes in patients with paroxysmal and persistent AF.

Improvement in quality of life after catheter ablation for paroxysmal versus long-standing persistent atrial fibrillation: a prospective study with 3-year follow-up.

Background Changes in quality of life (QoL) after catheter ablation for long‐standing persistent atrial fibrillation (LSPAF) are not well described. We sought to compare QoL improvement after catheter ablation of paroxysmal atrial fibrillation (PAF) versus that after LSPAF. Methods and Results A total of 261 PAF and 126 LSPAF ablation recipients were prospectively followed for arrhythmia recurrence, QoL, hospital stay, and sick leave. In PAF versus LSPAF groups, 1.3±0.6 versus 1.6±0.7 procedures were performed per patient (P<0.00001) during a 3‐year follow‐up. Good arrhythmia control was achieved in 86% versus 87% of patients (P=0.69) and in 69% versus 69% of patients not receiving antiarrhythmic drugs (P=0.99). The baseline QoL was better in the PAF than in the LSPAF group (European Quality of Life Group instrument self‐report questionnaire visual analog scale: 66.4±14.2 versus 61.0±14.2, P=0.0005; European Quality of Life Group 3‐level, 5‐dimensional descriptive system: 71.4±9.2 versus 67.7±13.8, P=0.002). Postablation 3‐year increase in QoL was significant in both groups (all P<0.00001) and significantly lower in PAF versus LSPAF patients (visual analog scale: +5.0±14.5 versus +10.2±12.8, P=0.001; descriptive system: +5.9±14.3 versus +9.3±13.9, P=0.03). In multivariate analysis, LSPAF, less advanced age, shorter history of AF and good arrhythmia control were consistently associated with postablation 3‐year improvement in QoL. Days of hospital stay for cardiovascular reasons and days on sick leave per patient/year were significantly reduced in both groups. Conclusions Patients with LSPAF had worse baseline QoL. The magnitude of QoL improvement after ablation of LSPAF was significantly greater compared with after ablation of PAF, particularly when good arrhythmia control was achieved without the use of antiarrhythmic drugs.

Septal ventricular tachycardia with alternating LBBB-RBBB morphology in isolated ventricular noncompaction.

Alternating VT Morphology in IVNC. Knowledge on ventricular tachycardia (VT) in isolated ventricular noncompaction (IVNC) is limited. We report on a patient with IVNC who presented with cardiogenic shock due to an incessant drug‐resistant VT that was cured by radiofrequency ablation. The VT had characteristics of a deep septal focal arrhythmia, which was distinctive by ablation‐induced alternation of the rightward and leftward exits, and was difficult to ablate from either side of the ventricular septum. (J Cardiovasc Electrophysiol, Vol. 21, pp. 704‐707, June 2010)

Sinus rhythm restoration and arrhythmia noninducibility are major predictors of arrhythmia-free outcome after ablation for long-standing persistent atrial fibrillation: A prospective study

BACKGROUND The impact of restoring sinus rhythm (SR) by initial ablation in patients with long-standing persistent atrial fibrillation (LSPAF) is not fully established. OBJECTIVE The purpose of this study was to investigate the prognostic value of SR restoration at the initial procedure and arrhythmia noninducibility at the final repeat procedure for long-term outcome. METHODS A total of 203 patients (22% female; age 59 ± 9 years) underwent stepwise catheter ablation for LSPAF. RESULTS The procedural end-point of SR restoration was achieved in 50% of patients. During follow-up (median 48 months) and after 1.7 procedures per patient, 72% of patients were free from arrhythmia off antiarrhythmic drugs. Failure to restore SR was independently predicted by left atrial (LA) long-axis diameter ≥68 mm (relative risk [RR] 1.55, P = .03], proportion of high-voltage LA sites <20% (RR 1.62, P = .02), and left atrial appendage (LAA) atrial fibrillation cycle length (AFCL) <155 ms (RR 1.5, P = .05). Arrhythmia recurrence after the initial procedure was predicted by SR nonrestoration (RR 2.99, P <.000001) and LAA AFCL ≥155 ms (RR 1.90, P = .0002). Arrhythmia recurrence after the final procedure was predicted by SR nonrestoration at the initial procedure (RR 2.83, P = .0007), persistent AF duration ≥24 months (RR 2.74, P = .002), LAA outflow velocity <40 cm/s (RR 2.21, P = .006), and LAA AFCL ≥155 ms (RR 1.92, P = .02). In 115 patients with repeat procedure(s), failure to achieve arrhythmia noninducibility at the final procedure (19% of patients) was associated with arrhythmia recurrence (RR 8.9, P < .000001). CONCLUSION SR restoration at the initial procedure and arrhythmia noninducibility at the last repeat procedure were major predictors of arrhythmia-free outcome after ablation for LSPAF.

Atrial fibrillation ablation: a cost or an investment?

In the last decade, catheter ablation (CA) became a viable therapeutic approach for symptomatic patients with atrial fibrillation (AF) non-responsive to antiarrhythmic drugs (AAD). The economic analysis of CA is complex due to the presence of several confounding factors, such as the pattern of AF (paroxysmal AF, persistent or long-term persistent AF), the patient population (age, presence/absence of underlying structural heart disease, comorbidities, etc.), the different techniques for ablation (with impact on complexity and cost of the procedure, as well as on efficacy and safety), and the learning curve and experience of an individual centre (with impact on efficacy and cost effectiveness). At present, CA appears to be cost effective mainly in patients with paroxysmal AF who are refractory to AADs, especially if the success of the procedure and, thus, the benefit in quality of life remains >5 years, with a low complication rate. More data are needed on cost effectiveness of CA of persistent and long-term persistent AF or of AF associated with heart failure. Atrial fibrillation ablation is unlikely to be cost effective for patients who have preserved quality of life despite their AF or for patients whose quality of life is not expected to improve substantially despite elimination of AF (e.g. patients with poor quality of life mainly due to other health problems). These observations may help in the selection of candidates for AF ablation.

Functional improvement after successful catheter ablation for long-standing persistent atrial fibrillation

Aims Identifying patients who benefit from restored sinus rhythm (SR) would optimize the selection of candidates for ablation of long-standing persistent atrial fibrillation (LSPAF). This prospective study sought to identify the hitherto unknown factors associated with global functional improvement after successful radiofrequency catheter ablation of LSPAF. Methods and results In 171 LSPAF patients (84% of the total consecutive 203 patients) who were examined in SR 12 months after ablation, the individual per cent change from baseline value in maximum oxygen consumption at exercise test (VO2 max), left ventricular ejection fraction (LVEF), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and five-dimensional descriptive system (EQ-5D) of quality-of-life questionnaire were classified in quartiles by 0 (worse) to 3 (best) grades. The individual grades were summed into a composite score (SCORE, 0 … 12) reflecting global functional improvement. Significant improvement in VO2 max (3.4 ± 4.7 mL/kg/min), LVEF (7.5 ± 9.1%), NT-proBNP (-861 ± 809 pg/mL), and EQ-5D (0.7 ± 0.12) was observed (all P < 0.0001). On multivariable analysis, younger age (P = 0.001), male gender (P = 0.02), timely post-ablation left atrial appendage (LAA) outflow (P = 0.005) with improvement in outflow velocity (P = 0.0002), and withdrawal of Class I/III antiarrhythmic drugs (P < 0.05) were positively and independently correlated with the SCORE. Conclusions Younger male patients benefited most from catheter ablation of LSPAF. Delayed or non-improved LAA outflow and inability to discontinue Class I/III antiarrhythmic medication reduced the post-ablation functional improvement.

Multivariate Analysis of Correspondence between Left Atrial Volumes Assessed by Echocardiography and 3-Dimensional Electroanatomic Mapping in Patients with Atrial Fibrillation

Background Left atrial (LA) enlargement is a predictor of worse outcome after catheter ablation for atrial fibrillation (AF). Widely used two-dimensional (2D)-echocardiography is inaccurate and underestimates real LA volume (LAV). We hypothesized that baseline clinical characteristics of patients can be used to adjust 2D-ECHO indices of LAV in order to minimize this disagreement. Methods The study enrolled 535 patients (59 ± 9 years; 67% males; 43% paroxysmal AF) who underwent catheter ablation for AF in three specialized centers. We investigated multivariately the relationship between 2D-echocardiographic indices of LA size, specifically LA diameter in M-mode in the parasternal long-axis view (LAD), LAV assessed by the prolate-ellipsoid method (LAVEllipsoid), LAV by the planimetric method (LAVPlanimetry), and LAV derived from 3D-electroanatomic mapping (LAVCARTO). Results Cubed LAD of 106 ± 45 ml, LAVEllipsoid of 72 ± 24 ml and LAVPlanimetry of 88 ± 30 ml correlated only modestly (r = 0.60, 0.69, and 0.53, respectively) with LAVCARTO of 137 ± 46 ml, which was significantly underestimated with a bias (±1.96 standard deviation) of -31 (-111; +49) ml, -64 (-132; +2) ml, and -49 (-125; +27) ml, respectively; p < 0.0001 for their mutual difference. LA enlargement itself, age, gender, type of AF, and the presence of structural heart disease were independent confounders of measurement error of 2D-echocardiographic LAV. Conclusion Accuracy and precision of all 2D-echocardiographic LAV indices are poor. Their agreement with true LAV can be significantly improved by multivariate adjustment to clinical characteristics of patients.

Comparison of two modes of long-term ECG monitoring to assess the efficacy of catheter ablation for paroxysmal atrial fibrillation

AIMS Optimal ECG monitoring in detecting recurrences of atrial fibrillation (AF) or atrial tachycardia (AT) after catheter ablation has not been well established. The purpose of this prospective study was to compare the utility of daily ECG monitoring with episodic card recorder (ECR) vs. periodic monitoring with episodic loop recorder (ELR) for the detection of post-blanking AF/AT recurrences during early (Months 4-6) and late (Months 7-12) periods after catheter ablation for paroxysmal AF. METHODS The study included 105 consecutive patients, who received ECR for 12 months and were instructed to send at least 2 random ECG recordings daily with extra-recordings during symptoms. The patients were simultaneously monitored for one week with ELR at the end of each period (Months 6 and 12). RESULTS Thirty-one and 12 patients with AF/AT recurrence were identified by means of ECR and ELR, respectively. In patients with complete and valid data, ELR technology was inferior to ECR by detecting AF/AT in 5 (31%) of 16 and 5 (26%) of 19 patients with arrhythmia identified by ECR in the early and late period, respectively. Overall, ELR had a sensitivity of 8/23 (35%) for detecting AF/AT recurrence. There was no single patient with AF/AT recurrence on ELR that would not be known from ECR monitoring. Only 2 patients with arrhythmia recurrence were completely asymptomatic throughout the study period. CONCLUSION Daily ECG monitoring with ECR was better than periodic monitoring with ELR in detecting AF/AT recurrences during the follow-up periods. Entirely asymptomatic patients with AF/AT recurrences were rare.