Efforts to Enhance Catheter Stability Improve Atrial Fibrillation Ablation Outcome.
ABSTRACT BACKGROUND: Contemporary techniques to enhance anatomical detail and catheter contact during atrial fibrillation ablation include: 1) the integration of pre-acquired tomographic reconstructions with electroanatomical mapping (I-EAM); 2) the use streerable introducers (SI); and 3) high frequency jet ventilation (HFJV). OBJECTIVE: We hypothesized that using these stabilizing techniques during AF ablation would improve 1-year procedural outcome. METHODS: We studied 300 patients undergoing AF ablation at our institution. Patients were assigned to three equal treatment groups (100 patients each) based upon the tools utilized: 1) Group 1- AF ablation performed without I-EAM, SI or HFJV; 2) Group 2- AF ablation performed using I-EAM and SI, but without HFJV; and 3) Group 3- AF ablation performed with I-EAM, SI, and HFJV. The primary outcome was freedom from AF 1-year after a single ablation procedure. The burden of both acute and chronic PV reconnection was also assessed. RESULTS: Patients from Groups 2 and 3 had significantly more non-paroxysmal AF (17% vs. 30% vs. 39%, p=0.002), larger left atria (4.2±0.8 vs. 4.4±0.7 vs. 4.5±0.8 cm, p<0.001), and higher BMI (28.5±5.8 vs. 29.1±4.8 vs. 31.2±5.4, p<0.001). Despite these differences, with adoption of I-EAM, SI, and HFJV we noted a significant improvement in 1-year freedom from AF (52% vs. 66% vs. 74%; p=0.006) as well as fewer acute (1.1±1.2 vs. 0.9±1.1 vs. 0.6±0.9, p=0.03) and chronic (3.5±0.9 vs. 3.2±0.9 vs. 2.4±1.0, p=0.02) PV reconnections. CONCLUSIONS: The incorporation of contemporary tools to enhance anatomical detail and ablation catheter stability significantly improved 1-year freedom from AF after ablation.
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ABSTRACT: Autonomic modulation following catheter ablation of atrial fibrillation may promote the development of catecholamine-sensitive arrhythmias, such as outflow tract (OT) ventricular premature depolarizations (VPDs). The purpose of this study was to determine the incidence and prognostic significance of OT VPDs occurring in patients after atrial fibrillation (AF) ablation. We prospectively examined 53 consecutive patients undergoing wide-area circumferential antral pulmonary vein (PV) isolation; no patients had evidence of OT VPDs on 24 h of preprocedural telemetry monitoring. Cases (OT+) had postprocedure telemetry monitoring with > 30 continuous beats or > 3/min OT VPDs. Clinical follow-up included transtelephonic monitoring at 6 weeks, 6 months, and 1 year. The incidence of OT VPDs in this population was 11 % (6/53). There was no difference in AF recurrence at 1 year between those with or without OT VPDs (17 vs 28 %, p = 0.6). There was a strong association with higher immediate postprocedure heart rate (HR) in OT+ compared to OT- patients (86 vs 76, p = 0.03); this difference persisted at 1 year (79 vs 60, p < 0.01). OT VPDs resolved in 5/6 of the OT+ patients over the 1-year follow-up. In a multivariable linear regression model, OT VPDs were associated with higher HR (odds ratio (OR) 1.14 [1.10-1.18], p < 0.001) despite adjustment for medication dose. A minority of patients undergoing antral PV isolation develops OT VPDs associated with a sustained increase in mean heart rate; this effect may result from the modulation of adjacent autonomic ganglia.Journal of Interventional Cardiac Electrophysiology 06/2014; 41(2). DOI:10.1007/s10840-014-9914-y · 1.55 Impact Factor
Circulation Arrhythmia and Electrophysiology 10/2014; 7(5):781-4. DOI:10.1161/CIRCEP.114.002204 · 5.42 Impact Factor
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ABSTRACT: Background-Cardiac and respiratory movements cause catheter instability. Lateral catheter sliding over target endocardial surface can lead to poor tissue contact and unpredictable lesion formation. We describe a novel method of overcoming the effects of lateral catheter sliding movements using an electrogram-gated pulsed power ablation. Methods and Results-All ablations were performed on a thermochromic gel myocardial phantom. Ablation settings were randomized to conventional (nongated) 30 W versus electrogram-gated at 20% duty cycle (30 W average power) at 0-, 3-, 6-, and 9-mm lateral sliding distances. Forty-eight radiofrequency ablations were performed. Deeper lesions were created in electrogram-gated versus conventional ablations at 3 mm (4.36 +/- 0.08 versus 4.05 +/- 0.17 mm; P=0.009), 6 mm (4.39 +/- 0.10 versus 3.44 +/- 0.15 mm; P<0.001), and 9 mm (4.41 +/- 0.06 versus 2.94 +/- 0.16 mm; P << 0.001) sliding distances. Electrogram-gated ablations created consistent lesions at a quicker rate of growth in depth when compared with conventional ablations (P<0.001). Conclusions-(1) Lesion depth decreases and length increases in conventional ablations with greater degrees of lateral catheter movements; (2) electrogram-gated pulsed radiofrequency delivery negated the effects from lateral catheter movement by creating consistently deeper lesions irrespective of the degree of catheter movement; and (3) target lesion depths were reached significantly faster in electrogram-gated than in conventional ablations.Circulation Arrhythmia and Electrophysiology 08/2014; 7(5). DOI:10.1161/CIRCEP.113.001112 · 5.42 Impact Factor