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ABSTRACT: Radiofrequency transcatheter ablation is an effective and safe treatment for atrioventricular node reentry tachycardia. Slow pathway ablation is considered the ablative technique of choice, but when atrioventricular nodal reentrant tachycardia is associated with a prolonged PR interval at sinus rhythm, a higher risk of delayed atrioventricular (AV) block has been reported. Studies on the subject are few, enrolling low numbers of patients with variable selection criteria and producing different results. Hence, optimal ablation strategy remains controversial. The aim of this study is to review the available knowledge on the topic. Experience from our centers is also briefly reported.
Journal of Cardiovascular Medicine 02/2012; 13(5):325-9. · 1.51 Impact Factor
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Atul Verma,
Roberto Mantovan,
Laurent Macle,
Guiseppe De Martino,
Jian Chen,
Carlos A Morillo,
Paul Novak, Vittorio Calzolari,
Peter G Guerra,
Girish Nair,
Esteban G Torrecilla,
Yaariv Khaykin
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ABSTRACT: This multicentre, randomized trial compared three strategies of AF ablation: ablation of complex fractionated electrograms (CFE) alone, pulmonary vein isolation (PVI) alone, and combined PVI + CFE ablation, using standardized automated mapping software.
Patients with drug-refractory, high-burden paroxysmal (episodes >6 h, >4 in 6 months) or persistent atrial fibrillation (AF) were enrolled at eight centres. Patients (n = 100) were randomized to one of three arms. For CFE alone (n = 34), spontaneous/induced AF was mapped using validated, automated CFE software and all sites <120 ms were ablated until AF termination/non-inducibility. For PVI (n = 32), all four PV antra were isolated and confirmed using a circular catheter. For PVI + CFE (n = 34), all four PV antra were isolated, followed by AF induction and ablation of all CFE sites until AF termination/non-inducibility. Patients were followed at 3, 6, and 12 months with a visit, ECG, 48 h Holter. Atrial fibrillation symptoms were confirmed by loop recording. Repeat procedures were allowed within the first 6 months. The primary endpoint was freedom from AF >30 s at 1 year. Patients (age 57 +/- 10 years, LA size 42 +/- 6 mm) were 35% persistent AF. In CFE, ablation terminated AF in 68%. Only 0.4 PVs per patient were isolated as a result of CFE. In PVI, 94% had all four PVs successfully isolated. In PVI + CFE, 94% had all four PVs isolated, 76% had inducible AF with additional CFE ablation, with 73% termination of AF. There were significantly more repeat procedures in the CFE arm (47%) vs. PVI (31%) or PVI + CFE (15%) (P = 0.01). After one procedure, PVI + CFE had a significantly higher freedom from AF (74%) compared with PVI (48%) and CFE (29%) (P = 0.004). After two procedures, PVI + CFE still had the highest success (88%) compared with PVI (68%) and CFE (38%) (P = 0.001). Ninety-six percent of these patients were off anti-arrhythmics. Complications were two tamponades, no PV stenosis, and no mortality.
In high-burden paroxysmal/persistent AF, PVI + CFE has the highest freedom from AF vs. PVI or CFE alone after one or two procedures. Complex fractionated electrogram alone has the lowest one and two procedure success rates with a higher incidence of repeat procedures. ClinicalTrials.gov identifier number NCT00367757.
European Heart Journal 03/2010; 31(11):1344-56. · 10.48 Impact Factor
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Alessandro Proclemer,
Giuseppe Allocca,
Dario Gregori,
Carlo Bonanno,
Renato Ometto,
Alessandro Fontanelli,
Roberto Mantovan,
Martino Crosato, Vittorio Calzolari,
Daisy Pavoni,
Domenico Facchin,
Luca Rebellato,
Paolo M Fioretti
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ABSTRACT: To compare clinical characteristics, procedure complexity, acute and long-term outcome of 'ablate and pace' (A&P) with pulmonary vein isolation (PVI) in patients with drug-refractory atrial fibrillation (AF). So far, only few small studies have compared the two procedures.
We analysed retrospectively a cohort of symptomatic consecutive patients with drug-refractory AF. Group 1 included 100 patients treated with A&P and Group 2 included 144 patients treated with PVI. Group 1 patients were older (74 +/- 8 vs. 56 +/- 9 years; P < 0.0001), had lower left ventricular ejection fraction (50 +/- 13% vs. 59 +/- 7%; P < 0.05), and a lower prevalence of paroxysmal AF (46% vs. 65%; P < 0.05). Acute success was not statistically different (98% vs. 92.3%, P = ns). Group 1 patients had shorter procedure time and lower radiation exposure with respect to Group 2 patients (70 +/- 15 vs. 204 +/- 58 min, and 8 +/- 4 vs. 57 +/- 22 min; P < 0.0001, respectively). After a median follow-up of 29 months (I, III quartile; 15, 40 months) vs. 25 months (I, III quartile; 8, 36 months) (P = ns), all the patients in Group 1 were free of symptomatic AF, while 113 patients (79%) of Group 2 were in stable sinus rhythm (P < 0.0001). Persistent or permanent AF has been documented in 58 patients (58%) of Group 1 vs. 11 (8%) of Group 2 (P < 0.0001).
In this series (i) patients treated with A&P and PVI for drug-refractory AF showed significant differences in clinical profile; (ii) A&P is a shorter and less complex procedure, but is associated with a higher rate of persistent AF; (iii) symptomatic recurrences of paroxysmal AF were more frequent in PVI group. Randomized studies appear necessary to identify the best strategy in selected cases.
Europace 10/2008; 10(9):1085-90. · 1.98 Impact Factor
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ABSTRACT: Advanced heart failure (HF) and related acute decompensations have become the single most costly medical syndrome in cardiology.
HF leads to frequent re-hospitalizations: in the US alone, yearly HF hospitalizations number more than 1 million [1]. A recent analysis carried out in all European countries led to the conclusion that 75% of all HF-related costs have to
be attributed to HF hospitalizations [2].
12/2006: pages 129-136;
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ABSTRACT: Pulmonary vein (PV) disconnection by radiofrequency (RF) catheter ablation has been reported to cure atrial fibrillation (AF). Different techniques have been proposed. The aim of this study was to evaluate the technical limitations of both anatomical and electrophysiological approaches.
A total of 110 PVs were ablated in 26 consecutive patients (23 male, 3 female, mean age 51 +/- 9.5 years) with paroxysmal (n = 19, 73%), persistent (n = 3, 12%) or permanent (n = 4, 15%) AF. Accurate reconstructions of the PV ostia were obtained using fluoroscopy, electrophysiology, and the CARTO mapping system. Electrophysiological mapping was attempted in all PVs by means of a decapolar circular catheter. RF ablation was performed in a single-blind fashion in order to anatomically create circumferential lines around each PV. Completeness of anatomically-guided, circumferential RF lesions around the PVs was established by the physician using the CARTO system, who was unaware of the decapolar circular catheter electrophysiological recordings of the PVs. If PV potentials persisted, RF delivery was targeted to the electrophysiological breakthroughs.
All PV ostia were anatomically ablated by performing circumferential RF lesions. Among 110 PVs, 73 (66%) were fully mapped by use of circular catheters. After anatomical ablation, electrical disconnection was achieved in 44/73 PVs (60%). In the remaining 29 PVs (40%), a median of one RF pulse (mean 1.8 +/- 1.4) was necessary to achieve complete PV disconnection. Total procedure duration, fluoroscopy time, and RF delivery time were 232 +/- 29, 50 +/- 16 and 39 +/- 11 min, respectively. Pericardial effusion occurred in one patient after the procedure. After 10.5 +/- 6.4 months, 21 patients (81%) were in stable sinus rhythm and 13 of them (62%) discontinued all drugs after 6 months. Only 4 patients (15%) required two procedures.
Electrical PV disconnection cannot be achieved in many PVs by means of a pure anatomical approach. On the other hand, electrophysiological mapping cannot be performed in many PVs owing to anatomical variations. An integrated approach might overcome these limitations.
Journal of Cardiovascular Medicine 09/2006; 7(8):586-91. · 1.51 Impact Factor
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ABSTRACT: The aim of this study was to compare the outcome of anatomical pulmonary vein (PV) radiofrequency (RF) ablation with that of an integrated approach (anatomical with electrophysiological confirmation of PV disconnection).
Sixty consecutive patients affected by drug-refractory paroxysmal (39), persistent (13), and permanent (8) atrial fibrillation (AF) were assigned to an anatomical (group A: 30 patients; 25 male, 5 female, mean age: 55 +/- 7 years) or integrated approach (group B: 30 patients; 26 male, 4 female, mean age: 52 +/- 9 years). In all cases, RF ablation was performed by means of the Carto system in order to anatomically create circumferential lines around PVs. In group B, the persistence of PV potentials was then assessed with a multipolar circular catheter. If PV potentials persisted, RF pulses targeting the electrophysiological breakthroughs were delivered to disconnect PVs.
Total procedure duration, fluoroscopy time, and RF delivery time were similar in both groups: 227 +/- 43, 50 +/- 23, and 43 +/- 16 minutes (group A); 232 +/- 32, 55 +/- 15, and 42 +/- 10 minutes (group B), respectively (ns). One asymptomatic PV stenosis and one pericardial effusion occurred in group A and B, respectively. After 15.4 +/- 7.4 months, 17 (57%) group A patients and 25 (83%) group B patients were in stable sinus rhythm (P = 0.02) (RR 1.78; 95% CI: 1.7-2.9).
PV ablation by means of an integrated anatomical and electrophysiological approach seems more effective than a purely anatomical RF ablation approach. Electrophysiological confirmation of PV disconnection could be a useful marker of successful RF treatment of AF.
Journal of Cardiovascular Electrophysiology 01/2006; 16(12):1293-7. · 3.06 Impact Factor
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Journal of Cardiovascular Electrophysiology 08/2005; 16(7):804-6. · 3.06 Impact Factor
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Journal of Cardiovascular Electrophysiology 05/2002; 13(4):413. · 3.06 Impact Factor
