Efficacy and Safety of Combined Endocardial/Epicardial Catheter Ablation for Ventricular Tachycardia in Chagas Disease. A Randomized Controlled Study.
- 作者列表："Pisani CF","Romero J","Lara S","Hardy C","Chokr M","Sacilotto L","Wu TC","Darrieux F","Hachul D","Kalil-Filho R","Di Biase L","Scanavacca M
BACKGROUND:Epicardial mapping and ablation are frequently necessary to eliminate ventricular tachycardia (VT) in Chagas disease patients. Nonetheless, there are no randomized controlled trials demonstrating the role of this strategy. OBJECTIVE:We conducted this randomized controlled trial to evaluate the efficacy and safety of combined epicardial ablation in Chagas disease patients. METHODS:We randomized patients with Chagas disease and VT in a 1:1 fashion to either endocardial (endo) mapping and ablation group or combined endocardial/epicardial (endo/epi) mapping and ablation group. The efficacy endpoints were measured by VT inducibility and all-ventricular arrhythmia recurrence. Safety was assessed by the rate of periprocedural complications. RESULTS:Thirty patients were enrolled, most were male, the median age was 67 (58;70) years on endo-only and 58 (43;66) years on the endo/epi group. Left ventricular ejection fraction was 33.0±9.5% and 35.2±11.5%, respectively. Acute success (non-reinducibility of clinical VT) was obtained in 13 (86%) patients in the endo/epi group and in six (40%) patients in the endo-only group (p=0.021). There were 12 patients with VT recurrence (80%) in the endo-only group and six patients (40%) in the endo/epi group (P=0.02) (by intention-to-treat). Epicardial ablation was ultimately performed in nine (60%) patients in the endo-only group due to an absence of endocardial scar or maintenance of VT inducibility. There was no difference in complications between groups. CONCLUSION:Combining endo/epi VT catheter ablation in patients with Chagas disease significantly increases short and long-term freedom from all-ventricular arrhythmias. Epicardial access did not increase periprocedural complication rates.
背景: 在恰加斯病患者中，心外膜标测和消融通常是消除室性心动过速 (VT) 所必需的。尽管如此，没有随机对照试验证明这种策略的作用。 目的: 我们进行了这项随机对照试验，以评估联合心外膜消融治疗恰加斯病患者的疗效和安全性。 方法: 我们以 1:1 的方式将恰加斯病合并 VT 的患者随机分为心内膜标测和消融组或心内膜/心外膜联合标测和消融组。通过 VT 诱导性和全室性心律失常复发测量疗效终点。通过围手术期并发症发生率评估安全性。 结果: 纳入 30 例患者，大多数为男性，中位年龄为 67 (58; 70) 岁，仅 endo-and 58 (43; 66) endo/epi 组年。左室射血分数分别为 33.0 ± 9.5% 和 35.2 ± 11.5%。Endo/epi 组 13 例 (86%) 患者获得急性成功 (临床 VT 的非再诱导性)，6 例 (40%) 患者获得急性成功 endo-only 组患者 (p = 0.021)。仅 endo 组有 12 例 VT 复发 (80%)，endo/epi 组有 6 例 (40%) (P = 0.02) (通过意向治疗)。仅 endo 组中有 9 例 (60%) 患者由于没有心内膜瘢痕或维持 VT 可诱导性而最终进行心外膜消融。组间并发症无差异。 结论: 联合 endo/epi VT 导管消融治疗恰加斯病患者可显著增加短期和长期无室性心律失常的发生。心外膜通路未增加围手术期并发症发生率。
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.