[Show abstract][Hide abstract] ABSTRACT: Objective The purpose of the present study was to determine the incidence of ventricular arrhythmias before and after alcohol septal ablation (ASA).
Background In patients with hypertrophic obstructive cardiomyopathy (HOCM), gradient reduction by ASA is an alternative for surgical myectomy. However, concerns exist about whether the induction of a myocardial scar during ASA may create substrate for ventricular arrhythmias.
Methods The study group consisted of 44 patients in whom ASA was performed for symptomatic, drug-refractory hypertrophic cardiomyopathy. Continuous rhythm monitoring was obtained by implantable loop recorder (n=30) or pacemaker (n=14). Occurrence of ventricular and supraventricular arrhythmias before and after ASA was noted, retrospectively.
Results The ASA procedure was considered successful (resting gradient <30 mm Hg, and provoked gradient <50 mm Hg at 4 months in combination with NYHA Class functional status ≤2) in 30 (68%) patients. Rhythm monitoring before ASA was available in 28 patients. The median duration of rhythm monitoring after ASA was 3.0 years (IQR 1.3–4.3). Sustained VT/VF within 30 days after ASA occurred in three patients (7%), including 2 cases of procedural VF, while no VT/VF was observed before ASA (p=0.10). No sustained VT/VF was observed >30 days after ASA. No cardiac deaths occurred during follow-up.
Conclusions In a low-risk cohort of patients who underwent ASA, in which continuous rhythm monitoring was performed, sustained VT or VF within 30 days occurred in 3 patients (7%) while no VT/VF was observed before ASA. During long-term follow-up, no sustained VT or VF was observed >30 days after ASA.
[Show abstract][Hide abstract] ABSTRACT: Recently, a multi-electrode catheter system using phased radiofrequency (RF) energy was developed specifically for atrial fibrillation (AF) ablation: the pulmonary vein ablation catheter (PVAC), the multi-array septal catheter (MASC), and the multi-array ablation catheter (MAAC). Initial results of small trials have been promising: shorter procedure times and low adverse event rates. In a large single-centre registry, we evaluated the adverse events associated with multi-electrode ablation catheter procedures with PVAC alone, or combined with MASC and MAAC.
In all, 634 consecutive patients with AF had 663 procedures with multi-electrode ablation catheters, 502 patients with the PVAC alone, 128 patients with PVAC/MASC/MAAC, 29 redo procedures with the PVAC or PVAC/MASC/MAAC, and 4 patients had a complicated transseptal puncture. Major and minor adverse events during 6 month follow-up were registered. In 15 cases (2.3%), major adverse events were seen within the first month after the procedure. These included complicated transseptal puncture (4), stroke (2), transient ischaemic attack (5), acute coronary syndrome (2), femoral pseudoaneurysm (1), and arteriovenous fistulae (1). Minor adverse events were seen in 10.7% at 6 months, mostly due to femoral haematoma (3.9%), and non-significant PV stenosis (5.2%). There was no difference in the occurrence of major adverse events between PVAC alone, or PVAC/MASC/MAAC ablation.
Ablation with phased RF and multi-electrode catheters is accompanied by a major adverse event rate of 2.3% within 1 month and a minor event rate of 10.7% at 6 months.
[Show abstract][Hide abstract] ABSTRACT: In patients with paroxysmal atrial fibrillation (PAF) the pattern of atrial fibrillation (AF) episodes and the total AF burden, may be related to the efficacy of pulmonary vein isolation (PVI). We evaluated (pre)-procedural factors explaining the long-term outcome after PVI, using a ring-shaped multielectrode ablation catheter [pulmonary vein ablation catheter (PVAC)].
A total of 120 consecutive patients with PAF were treated with the PVAC. The patients' histories were obtained by a questionnaire and the clinical charts. Follow-up was performed at 3, 6, 12, 18, and 24 months with serial electrocardiogram, and multiple day Holter at 6, 12, and 24 months, as well as event recording in case of unexplained palpitations. At 1 year, 66 of 120 (55%, 95% confidence interval (CI) [46-63%]) patients were free of any left atrial (LA) arrhythmia without class I or III anti-arrhythmics after a single procedure. At 2 years, freedom from LA arrhythmia slightly declined further to 58 of 119 (49%, 95% CI [40-58%]). The only pre-procedural predictor of long-term success was a shorter duration of the longest episode of AF (hazard ratio (HR) 0.77 95% CI [0.64-0.92]). The only procedural predictor of long-term success was no need for direct current cardioversion (DCCV) for AF (HR 0.36 95% CI [0.21-0.61]). Since other characteristics in these PAF patients were very homogeneous, no further clinical predictors were observed.
Freedom from LA arrhythmia after PVI for PAF with PVAC is 49% after 2-year follow-up, with little decline between year 1 and 2. Predictors of long-term failure were a longer duration of the longest episode of AF in the pre-procedural questionnaire, and a procedural DCCV for AF.
[Show abstract][Hide abstract] ABSTRACT: After pulmonary vein isolation (PVI), patients need to be followed to analyze the effect of the treatment. We evaluated the influence of the duration of Holter monitoring on the detection of arrhythmia recurrences after a single PVI at 12 months.
Consecutive patients with paroxysmal atrial fibrillation (AF) underwent successful PVI with phased radiofrequency and pulmonary vein ablation catheter. Follow-up was performed with electrocardiogram at 3, 6, and 12 months and 7-day Holter at 12 months. Symptomatic patients received additional event recording. The 7-day Holters at 12 months were evaluated for documented left atrial tachyarrhythmia recurrences, and each individual day with AF was categorized.
At 12 months after the procedure, 21 of the 96 (22%) patients had AF on their 7-day Holter. In the patients with AF recurrence, there was an increase in sensitivity from 53% of a 1-day Holter up to 88% with 4-day Holter, and 100% of a 7-day Holter. Monitoring with duration of less than 4 days resulted in significantly less detection of patients with AF compared to 7-day Holter.
A 4-day Holter at 12 months has an 88% sensitivity for arrhythmia detection, and appears to provide a sufficient monitoring time. Prolonging the monitoring time to 7 days does not significantly increase the yield.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Early arrhythmia recurrences after pulmonary vein isolation (PVI) for atrial fibrillation (AF) are accepted as part of the blanking period. Their relevance for long-term efficacy is not well-known. We evaluated patients, who came to hospital with a documented recurrence of AF, or had a registered episode of AF on the 24-hour Holter 6weeks after PVI and compared it with long-term outcome. METHODS: One hundred consecutive patients with paroxysmal AF were treated with the PVAC. In the 3-month blanking period patients who came to hospital with a documented recurrence of AF on ECG were recorded. 6weeks after procedure a 24-hour Holter was performed. After 3months patients were asked if they felt a relapse. Follow-up was performed at 3, 6, and 12months with ECG, 7-day Holter at 6 and/or 12months, and event recording if needed. RESULTS: Within the blanking period, 25/100 (25%) patients had a documented recurrence of AF while 46/100 (46%) patients felt a relapse. After the blanking period up to 12months, 53/100 (53%) patients were free of AF without anti-arrhythmic drugs. Multivariate regression analyses revealed that absence of AF in the blanking period (OR 0.22 95%CI [0.05-0.98]) and absence of a relapse of symptoms suspect for AF during the blanking period (OR 0.21 95%CI [0.06-0.52]) were independent predictors of successful long-term outcome. CONCLUSIONS: Poor long-term outcome is strongly related to patients who experienced palpitations with ECG documented AF, AF on the 24-hour Holter at 6weeks after PVI and a relapse in the blanking period.
International journal of cardiology 08/2011; 165(1). DOI:10.1016/j.ijcard.2011.07.079 · 4.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated the effect of pulmonary vein (PV) anatomical characteristics on PV isolation (PVI) and long-term efficacy of ablation with phased radiofrequency (RF) energy and pulmonary vein ablation catheter (PVAC) multi-electrode catheter.
Before the procedure, PV anatomy was visualized by magnetic resonance imaging (MRI). Consecutive patients with paroxysmal atrial fibrillation were treated with the PVAC with successful acute isolation. Follow-up was performed at 3, 6, and 12 months with electrocardiogram and 7-day Holter recording at 6 and/or 12 months. Symptomatic patients received additional event recording. In 110 patients a pre-procedure cardiac MRI was performed. Ninety-seven (88%) had a separate left superior PV and separate left inferior PV, all patients had a separate right superior PV and separate right inferior PV. Fourteen (13%) had a left PV with common trunk and 27 (25%) had a separate right middle PV (RMPV). After a follow-up of 1 year, 57 of 110 (52%) patients were free of AF without anti-arrhythmic drug. No specific anatomical variable that was related to long-term failure could be found. There was a trend for patients with larger veins (>24 mm) or separate RMPV to have a lower efficacy. The number of applications per vein or procedure did not influence long-term outcome.
In patients who have undergone PVI with phased RF energy and PVAC multi-electrode ablation, long-term efficacy is not significantly affected by PV anatomy or number of applications, although a trend for reduced efficacy is seen for PV with diameter >24 mm, and presence of RMPV.
[Show abstract][Hide abstract] ABSTRACT: Ablation for persistent atrial fibrillation (AF) remains a difficult and time-consuming procedure with varying degrees of success. We evaluated the long-term effects of a novel approach for ablation of persistent AF using multi-electrode catheters.
In 89 patients with longstanding persistent AF (>1 year), multi-electrode ablation was performed with a pulmonary vein ablation catheter (PVAC), a multi-array septal catheter (MASC), and a multi-array ablation catheter (MAAC) for ablation of complex-fractionated atrial electrograms (CFAE) at the septum, left atrial (LA) roof, floor, posterior wall, and mitral isthmus. Follow-up was performed at 6 and 12 months with electrocardiogram, 7 days Holter, and occasionally ambulant event recordings. Average procedure and fluoroscopy times were 112 ± 32 and 21 ± 10 min. The pre-specified endpoint of pulmonary vein isolation and LA CFAE ablation was reached in all patients. No procedural complications were observed. At 12 months after a single treatment 44 of 89 (49%) remained in sinus rhythm, including direct current cardioversion in 12 patients. At 12 months, after a redo PVAC/MASC/MAAC, an additional 6 of 15 patients (40%) were free of AF. In 18 of 89 (20%) patients AF was changed to paroxysmal.
In this single centre study, ablation for longstanding persistent AF with the PVAC/MASC/MAAC resulted in 56% freedom of AF at 1 year after 1.2 ± 0.4 procedures. This approach is time efficient and has a favourable safety profile.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Similar to the effect of systemic hypertension on left ventricular disease in which both supra-ventricular tachyarrhythmia and ventricular arrhythmias are more common, it has been postulated that structural changes and enlargement of the right atrium and right ventricle in pulmonary hypertension (PHTN) may predispose patients with PHTN to arrhythmias. The incidence and clinical relevance of supra-ventricular arrhythmias and ventricular arrhythmias in PHTN have not been thoroughly evaluated.
Methods: Using the Nationwide Inpatient Sample (NIS) 2007, patients aged 18 or more discharged with a diagnosis of PHTN were identified using ICD-9-clinical modification codes 415.0 and 416.x. All discharges with primary diagnosis of atrial fibrillation (AF), atrial flutter (AFL) and paroxysmal supra-ventricular tachycardia (PSVT) was also identified using appropriate ICD-9 codes. Multivariate logistic regression was performed using appropriate survey commands in STATA to find the frequency and association between the above arrhythmias and PHTN. The analysis was adjusted for age, sex, race, hyperthyroidism, congestive heart failure, coronary artery disease, hypertension, valvular disorders and other relevant co-morbid conditions related to supra-ventricular arrhythmias.
Results: In 2007, there were an estimated 575307 (1.76%) adult discharges with PHTN in NIS. Out of those, 199752 (34.7%) had AF, 19088 (3.3%) had AFL and 24667 (4.3%) with PSVT. The patients with PHTN had 3.6 times higher frequency for AF, 3.7 times higher frequency of AFL and 3.2 times higher frequency of PSVT when compared to those without PHTN.
This persisted even after adjustment for various factors described above. There was significantly higher frequency of AF (Odds Ratio (OR) 1.97; 95% Confidence Interval (CI) 1.92-2.03), AFl (OR 1.68; 95%CI 1.59-1.76) and PSVT (OR 1.36; 95%CI 1.30-1.43) in patients with PHTN.
AF was found to be independent predictor for mortality in patients with pulmonary hypertension (OR 1.13; 95%CI 1.06-1.23).
Conclusion: This observational study shows increased frequency of AF, AFL and PSVT in patients with PHTN. Further prospective studies are needed to evaluate the causal relation.
[Show abstract][Hide abstract] ABSTRACT: Torsade de pointes (TdP), a ventricular tachycardia (VT) with the peaks of QRS complexes twisting around the iso-electric baseline and progressive amplitude and polarity variations, is mostly associated with long (congenital or acquired) QT syndromes (LQTS) and long coupling intervals of the initiating complex. We describe a patient with variant, short-coupled TdP, a normal QTc interval and without demonstrable structural heart disease. Mechanisms remain unclear but there may be a relationship with autonomic nervous system imbalance. Since anti-arrhythmic drug efficacy is uncertain, ICD-implantation seems the first-line therapy. If ventricular arrhythmia recurs despite drug therapy, catheter-ablation of initiating premature ventricular beats may be warranted.
[Show abstract][Hide abstract] ABSTRACT: Abstract A 64-year-old male, with a history of a lateral myocardial infarction, presented with haemodynamically well-tolerated incessant
therapy-resistant slow monomorphic ventricular tachycardia (mVT), despite implantable cardioverter defibrillator and antiarrhythmic
Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation 02/2010; 18(2):103-4. DOI:10.1007/BF03091746 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The first revision of the the practice guideline 'Atrial fibrillation' from the Dutch College of General Practitioners has provided an important document. Atrial fibrillation is a growing problem in clinical practice. Harmonization of general practice with cardiological guidelines will undoubtedly have favourable results, with as consequences improvement of the diagnostic outcome and state of the art treatment at an earlier moment. It can be expected, that the revised version of the Dutch College of General Practitioners' practice guideline will greatly contribute to the dialogue between cardiologist and general practitioner and may perhaps lead to joint research.
Nederlands tijdschrift voor geneeskunde 01/2010; 154:A2478.
[Show abstract][Hide abstract] ABSTRACT: Left atrial (LA) stretch-associated electrophysiological changes in patients with mitral stenosis (MS) predispose to atrial fibrillation. We hypothesized that the normalization of the pressure gradient by percutaneous transvenous mitral balloon valvotomy (PTMV) affects LA but not right atrial (RA) conduction, depending on the site of stimulation. Because direction-dependent (asymmetric) changes of conduction may contribute to arrhythmogenesis, we assessed conduction symmetry in MS patients and tested whether it is restored by PTMV.
In nine patients with MS, atrial effective refractory period and local activation times (ATs) were determined during stimulation before and after PTMV, with up to four decapolar catheters (LA and RA). Eight patients with ventricular pre-excitation served as controls. ATs at basic cycle length were similar before and after PTMV. With stimulation from either atrium, they were about 45 ms in the ipsilateral atrium and about 115 ms in the contralateral atrium. With premature stimulation, ATs increased dramatically. The shortest ATs were found in the RA with RA stimulation (78 +/- 9 and 80 +/- 6 ns, before and after PTMV). PTMV caused a shortening in LA-ATs (following LA stimulation) from 118 +/- 14 to 82 +/- 5 ms (before and after; P < 0.05). Asymmetry in conduction properties was therefore normalized by PTMV. PTMV led to a decrease in RA-ATs (following LA stimulation) from 196 +/- 11 to 174 +/- 13 ms (P < 0.02). In addition, following RA stimulation, the dispersion in ATs in the LA decreased significantly by PTMV (from 66 +/- 10 to 34 +/- 7 ms; P < 0.02).
MS is associated with LA conduction delay, increased LA dispersion of conduction, and conduction asymmetry. These changes are immediately reversible by PTMV.
Cardiovascular Research 11/2009; 85(4):711-8. DOI:10.1093/cvr/cvp374 · 5.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 58-year-old man with a history of alcohol abuse and smoking presented with a subdural haematoma due to head trauma after
alcohol intoxication. He was disorientated; general and specific cardiological and neurological examinationswere unremarkable.
Cardiac troponin T (0.053 μg/l), N-terminal pro-B type natriuretic peptide (768 pg/ml) and serum ethanol (3316 mg/l) were
Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation 10/2009; 17(10):396-7. DOI:10.1007/BF03086291 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pulmonary vein ablation with a single-tip catheter remains long and complex. We describe a typical case of a novel efficient technique with a decapolar ring catheter utilizing alternating unipolar/bipolar radiofrequency energy. Voltage analysis and electrical mapping demonstrate the potential for antrum ablation and pulmonary vein isolation.
[Show abstract][Hide abstract] ABSTRACT: Pulmonary vein (PV) isolation for ablation of atrial fibrillation (AF) remains a complex and lengthy procedure.
The purpose of this study was to evaluate the feasibility and safety of a novel multielectrode catheter that delivers duty-cycled bipolar and unipolar radiofrequency (RF) energy.
Patients eligible for catheter ablation of paroxysmal AF after screening with magnetic resonance imaging and transesophageal echocardiography were included in the study. A decapolar (3-mm electrode, 3-mm spacing, 25-mm diameter), circular, over-the-wire mapping and ablation catheter was deployed in the antrum of each PV. Ablation was performed with 60-second, 60 degrees C applications of duty-cycled bipolar/unipolar RF in a 4:1 ratio simultaneously at all selected electrode pairs until local activity was no longer observed. At 6 months, 7-day Holter monitoring was performed to determine freedom from AF without use of antiarrhythmic drugs.
In 98 patients (mean age 59 +/- 9 years), the PV ablation catheter was used for ablation of 369 veins (20 common left antra). All targeted veins (100%) were isolated as confirmed by the absence of potentials in the ostium either by PV ablation catheter or Lasso mapping. Mean number of RF applications was 27 +/- 7, total procedural time 84 +/- 29 minutes, and fluoroscopy time 18 +/- 8 minutes. Follow-up after 6 months without antiarrhythmic drugs showed freedom from AF in 83% of patients. No procedure-related complications were observed.
PV isolation by duty-cycled bipolar/unipolar low-power RF energy through a circular, decapolar catheter can be achieved safely and efficiently, with good efficacy at 6 months.
Heart rhythm: the official journal of the Heart Rhythm Society 01/2009; 5(12):1635-42. DOI:10.1016/j.hrthm.2008.08.037 · 5.08 Impact Factor