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Esophageal positions relative to the left atrium; data from 293 patients before catheter ablation of atrial fibrillation.

ABSTRACT: AIMS:Three-dimensional rotational angiography (3DRA) of the left atrium (LA) and the esophagus is a simple and safe method for analyzing the relationship between the esophagus and the LA during catheter ablation of atrial fibrillation. The purpose of this study is to describe the location of the esophagus relative to the LA and mobility of the esophagus during ablation procedure. METHODS:From 3/2011 to 9/2015, 3DRA of the LA and esophagus was performed in 326 patients before catheter ablation of atrial fibrillation. 3DRAwas performed with visualization of the esophagus via peroral administration of a contrast agent. The positions of the esophagus were determined at the beginning of the procedure, for part of patients also at the end of procedure with contrast esophagography. RESULTS:The most frequent position is behind the center of the LA (91 pts., 31.9%) The least frequent position is behind the right pulmonary veins (27 pts., 9.4%). The average shift of the esophagus position was 3.36±2.15mm, 3.59±2.37mm and 3.67±3.23mm for superior, middle and inferior segment resp. CONCLUSIONS:The position of the esophagus to the LA is highly variable. The most common position of the esophagus relative to the LA is behind the middle and left part of the posterior wall of the LA. The least frequently observed position is behind the right pulmonary veins. No significant position change of esophagus motion from before to after the ablation procedure in the majority (?95%) of the patients was observed.

SUBMITTER: Starek Z

PROVIDER: S-EPMC5902821 | biostudies-literature | 2018 Jan - Feb

REPOSITORIES: biostudies-literature

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Project description:Pulmonary vein isolation (PVI) with radiofrequency ablation (RFA) is the cornerstone of atrial fibrillation (AF) therapy, but few strategies exist for when it fails. To guide RFA, phase singularity (PS) mapping locates reentrant electrical waves (rotors) that perpetuate AF. The goal of this study was to test existing and develop new RFA strategies for terminating rotors identified with PS mapping. It is unsafe to test experimental RFA strategies in patients, so they were evaluated in silico using a bilayer computer model of the human atria with persistent AF (pAF) electrical (ionic) and structural (fibrosis) remodeling. pAF was initiated by rapidly pacing the right (RSPV) and left (LSPV) superior pulmonary veins during sinus rhythm, and rotor dynamics quantified by PS analysis. Three RFA strategies were studied: (i) PVI, roof, and mitral lines; (ii) circles, perforated circles, lines, and crosses 0.5-1.5 cm in diameter/length administered near rotor locations/pathways identified by PS mapping; and (iii) 4-8 lines streamlining the sequence of electrical activation during sinus rhythm. As in pAF patients, 2 ± 1 rotors with cycle length 185 ± 4 ms and short PS duration 452 ± 401 ms perpetuated simulated pAF. Spatially, PS density had weak to moderate positive correlations with fibrosis density (RSPV: r = 0.38, p = 0.35, LSPV: r = 0.77, p = 0.02). RFA PVI, mitral, and roof lines failed to terminate pAF, but RFA perforated circles and lines 1.5 cm in diameter/length terminated meandering rotors from RSPV pacing when placed at locations with high PS density. Similarly, RFA circles, perforated circles, and crosses 1.5 cm in diameter/length terminated stationary rotors from LSPV pacing. The most effective strategy for terminating pAF was to streamline the sequence of activation during sinus rhythm with >4 RFA lines. These results demonstrate that co-localizing 1.5 cm RFA lesions with locations of high PS density is a promising strategy for terminating pAF rotors. For patients immune to PVI, roof, mitral, and PS guided RFA strategies, streamlining patient-specific activation sequences during sinus rhythm is a robust but challenging alternative.

Project description:Background: Consistently successful patient outcomes following catheter ablation (CA) for treatment of persistent atrial fibrillation (pers-AF) remain elusive. We propose an electrocardiogram (ECG) analysis designed to (1) refine selection of patients most likely to benefit from ablation, and (2) examine the temporal evolution of AF organization indices that could act as clinical indicators of ongoing ablation effectiveness and completeness. Method: Twelve-lead ECG was continuously recorded in 40 patients (61 ± 8 years) during stepwise CA (step-CA) procedures for treatment of pers-AF (sustained duration 19 ± 11 months). Following standard pre-processing, ECG signals were divided into 10-s epochs and labeled according to their temporal placement: pre-PVI (baseline), dur-PVI (during pulmonary vein isolation), and post-PVI (during complex-fractionated atrial electrograms and linear ablation). Instantaneous frequency (IF), adaptive organization index (AOI), sample entropy (SampEn) and f-wave amplitude (FWA) measures were calculated and analyzed during each of the three temporal steps. Temporal evolution of these measures was assessed using a statistical test for mean value transitions, as an indicator of changes in AF organization. Results were then compared between: (i) patients grouped according to step-CA outcome; (ii) patients grouped according to type of arrhythmia recurrence following the procedure, if applicable; (iii) within the same patient group during the three different temporal steps. Results: Stepwise CA patient outcomes were as follows: (1) left-atrium (LA) terminated, not recurring (LTN, n = 8), (2) LA terminated, recurring (LTR, n = 20), and (3) not LA terminated, all recurring at follow-up (NLT, n = 12). Among the LTR and NLT patients, recurrence occurred as AF in seven patients and atrial tachycardia or atrial flutter (AT/AFL) in the remaining 25 patients. The ECG measures indicated the lowest level of organization in the NLT group for all ablation steps. The highest organization was observed in the LTN group, while the LTR group displayed an intermediate level of organization. Regarding time evolution of ECG measures in dur-PVI and post-PVI recordings, stepwise ablation led to increases in AF organization in most patients, with no significant differences between the LTN, LTR, and NLT groups. The median decrease in IF and increase in AOI were significantly greater in AT/AFL recurring patients than in AF recurring patients; however, changes in the SampEn and FWA parameters were not significantly different between types of recurrence. Conclusion: Noninvasive ECG measures, though unable to predict arrhythmia recurrence following ablation, show the lowest levels of AF organization in patients that do not respond well to step-CA. Increasing AF organization in post-PVI may be associated with organized arrhythmia recurrence after a single ablation procedure.

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Esophageal positions relative to the left atrium; data from 293 patients before catheter ablation of atrial fibrillation.

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