Right atrial conduction time for predicting coexistent typical atrial flutter in patients with paroxysmal atrial fibrillation.
- 作者列表："Higuchi S","Ejima K","Shoda M","Kanai M","Kataoka S","Yazaki K","Yagishita D","Yoshida A","Tanino S","Saito C","Yagishita Y","Arai K","Ashihara K","Hagiwara N
INTRODUCTION:Screening of coexistent typical atrial flutter (AFL) in patients with atrial fibrillation (AF) is sometimes challenging. This study investigated whether a prolonged right atrial conduction time (RACT) estimated by tissue Doppler imaging (TDI) predicts patients with concomitant AFL and AF. METHODS AND RESULTS:We retrospectively analyzed 398 patients (mean age 61.6 years, 73.4% men) undergoing catheter ablation of paroxysmal AF. The patients were classified into 2 groups according to whether they had evidence of AFL (N=122, 30.7%) determined by a clinical observation (N=68), induction during procedures (N=33), or AFL recurrence after procedures (N=21) or not (N=276, 69.3%). The preoperative RACT, defined as a longer duration between the onset of the P-wave and peak A'-wave on the right atrial lateral wall or septal wall, and total atrial conduction time (TACT), defined as the same time duration on the left atrial lateral wall, were evaluated in all patients. Patients with evidence of AFL had a significantly longer RACT than those without AFL (p<0.001). A multiple logistic regression and receiver operator characteristics curve analysis revealed the ratio of the RACT and TACT (RACT/TACT) was the independent and most superior accurate cofounder for predicting evidence of AFL (area under the curve 0.867). When adding a discriminator of an RACT/TACT≧93% into the conventional screening, 98.4% of the patients with evidence of AFL were estimated to be treated during the initial procedures. CONCLUSION:The estimated RACT/TACT using the TDI may be useful for predicting patients with concomitant AFL in patients with AF. This article is protected by copyright. All rights reserved.
引言: 在心房颤动 (AF) 患者中筛查并存的典型心房扑动 (AFL) 有时具有挑战性。本研究探讨组织多普勒成像 (TDI) 估计的右心房传导时间延长 (RACT) 是否可预测合并 AFL 和 AF 的患者。 方法和结果: 我们回顾性分析了 398 例接受阵发性 AF 导管消融的患者 (平均年龄 61.6 岁，73.4% 例男性)。根据临床观察结果 (N = 68) 确定患者是否有 AFL 证据 (N = 122，30.7%)，将患者分为 2 组,术中诱导 (N = 33)，或术后 AFL 复发 (N = 21) 或无 (N = 276，69.3%)。术前 RACT，定义为右房侧壁或间隔壁 P 波与 a '波峰值之间持续时间较长,所有患者均评估总心房传导时间 (TACT)，定义为左房侧壁相同的时间持续时间。有 AFL 证据的患者 RACT 显著长于无 AFL 的患者 (p<0.001)。多元 logistic 回归和接受者操作者特征曲线分析揭示了 RACT 和 TACT 的比率 (RACT/TACT) 是预测 AFL 证据的独立且最准确的共同创始人 (曲线下面积 0.867)。当在常规筛查中添加 RACT/tact ≧ 93% 的鉴别器时，估计 98.4% 有 AFL 证据的患者在初始手术过程中接受治疗。 结论: 使用 TDI 估计的 RACT/TACT 可能有助于预测 AF 患者合并 AFL 的患者。本文受版权保护。保留所有权利。
METHODS:AIMS:Pulmonary vein isolation (PVI) using ablation index (AI) incorporates stability, contact force (CF), time, and power. The CLOSE protocol combines AI and ≤6 mm interlesion distance. Safety concerns are raised about surround flow ablation catheters (STSF). To compare safety and effectiveness of an atrial fibrillation (AF) ablation strategy using AI vs. CLOSE protocol using STSF.,METHODS AND RESULTS:First cluster was treated using AI and second cluster using CLOSE. Procedural data, safety, and recurrence of any atrial tachycardia (AT) or AF >30 s were collected prospectively. All Classes 1c and III anti-arrhythmic drugs (AAD) were stopped after the blanking period. In total, all 215 consecutive patients [AI: 121 (paroxysmal: n = 97), CLOSE: n = 94 (paroxysmal: n = 74)] were included. Pulmonary vein isolation was reached in all in similar procedure duration (CLOSE: 107 ± 25 vs. AI: 102 ± 24 min; P = 0.1) and similar radiofrequency time (CLOSE: 36 ± 11 vs. AI: 37 ± 8 min; P = 0.4) but first pass isolation was higher in CLOSE vs. AI [left veins: 90% vs. 80%; P < 0.05 and right veins: 84% vs. 73%; P < 0.05]. Twelve-month off-AAD freedom of AF/AT was higher in CLOSE vs. AI [79% (paroxysmal: 85%) vs. 64% (paroxysmal: 68%); P < 0.05]. Only four patients (2%) without recurrence were on AAD during follow-up. Major complications were similar (CLOSE: 2.1% vs. AI: 2.5%; P = 0.87).,CONCLUSION:The CLOSE protocol is more effective than a PVI approach solely using AI, especially in paroxysmal AF. In this off-AAD study, 79% of patients were free from AF/AT during 12-month follow-up. The STSF catheter appears to be safe using conventional CLOSE targets.
METHODS:OBJECTIVE:To investigate the role of driver mechanism and the effect of electrogram dispersion-guided driver mapping and ablation in atrial fibrillation (AF) at different stages of progression.,METHODS:A total of 256 consecutive patients with AF who had undergone pulmonary vein isolation (PVI) plus driver ablation or conventional ablation were divided into three groups: paroxysmal atrial fibrillation (PAF; group A, n = 51); persistent atrial fibrillation (PsAF; group B, n = 38); and long standing-persistent atrial fibrillation (LS-PsAF; group C, n = 39). PVI was performed with the guidance of the ablation index. The electrogram dispersion was analyzed for driver mapping.,RESULTS:The most prominent driver regions were at roof (28.0%), posterior wall (17.6%), and bottom (21.3%). From patients with PAF to those with PsAF and LS-PsAF: the complexity of extra-pulmonary vein (PV) drivers including distribution, mean number, and area of dispersion region increased (P < .001). Patients who underwent driver ablation vs conventional ablation had higher procedural AF termination rate (76.6% vs 28.1%; P < .001). With AF progression, the termination rate gradually decreased from group A to group C, and the role of PVI in AF termination was also gradually weakened from group A to group C (39.6%, 7.4%, and 4.3%; P < .001) in patients with driver ablation. At the end of the follow-up, the rate of sinus rhythm maintenance was higher in patients with driver ablation than those with conventional ablation (89.1% vs 70.3%; P < .001).,CONCLUSION:The formation of extra-PV drivers provides an important mechanism for AF maintenance with their complexity increasing with AF progression. Electrogram dispersion-guided driver ablation appears to be an efficient adjunctive approach to PVI for AF treatment.
METHODS:PURPOSE:Whether or not pulmonary vein isolation (PVI) plus left atrial posterior wall isolation (PWI) using contact force (CF) sensing improves the ablation outcome for persistent atrial fibrillation (AF) is unclear. This study compared the outcome of PVI plus PWI and additional non-PV trigger ablation for persistent AF with/without CF sensing. METHODS:This retrospective cohort study analyzed 148 propensity score-matched persistent AF patients (median duration of persistent AF, 8 months (interquartile range, 3-24 months); left atrial diameter, 43 ± 7 mm) undergoing PVI plus PWI and ablation of non-PV triggers provoked by high-dose isoproterenol, including 74 with CF-sensing catheters (CF group) and 74 with conventional catheters (non-CF group). PVI plus PWI with no additional ablation but cavotricuspid isthmus ablation was performed without non-PV triggers in 48 CF patients (65%) and 54 non-CF patients (73%) (P = 0.38). In all other patients, we performed additional ablation of provoked non-PV triggers. RESULTS:The Kaplan-Meier estimate of the rate of freedom from atrial tachyarrhythmia recurrence of antiarrhythmic drugs at 12 months after the single procedure was higher in the CF group than in the non-CF group (85 vs. 70%, log-rank P = 0.030). A multivariable analysis revealed that using CF sensing and non-inducibility of AF from a non-PV trigger after PVI and PWI were significantly associated with a reduced rate of atrial tachyarrhythmia recurrence. CONCLUSIONS:Compared with non-CF sensing, PVI plus PWI and additional non-PV trigger ablation using CF-sensing catheters for persistent AF can reduce the rate of atrial tachyarrhythmia recurrence.