Dataset Information

Stepwise endo-/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach.

ABSTRACT:

Background

Outcomes of catheter ablation (CA) among patients with nonparoxysmal atrial fibrillation (AF) are largely disappointing.

Objective

We sought to evaluate the feasibility, effectiveness, and safety of a single-stage stepwise endo-/epicardial approach in patients with persistent/longstanding-persistent AF.

Methods

We enrolled 25 consecutive patients with symptomatic persistent (n = 4) or longstanding-persistent (n = 21) AF and at least one prior endocardial procedure, who underwent CA using an endo-/epicardial approach. Our anatomical stepwise protocol included multiple endocardial as well as epicardial (Bachmann's bundle [BB] and ligament of Marshall ablations) components, and entailed ablation of atrial tachycardias emerging during the procedure. The primary outcome was freedom from any AF/atrial tachycardia episode after a 3-month blanking period. The secondary outcome was patients' symptom status during follow-up.

Results

The stepwise endo-/epicardial approach allowed sinus rhythm restoration in 72% of patients, either directly (n = 6, 24%) or after AF organization into atrial tachycardia (n = 12, 48%). BB's ablation was commonly implicated in arrhythmia termination. After a median follow-up of 266 days (interquartile range, 96 days), survival free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be discontinued in 22 patients (88%). As compared to baseline, more patients were asymptomatic at 9-month follow-up (0% vs. 56%, p = .02). Five patients (20%) developed mild medical complications, whereas one subject (4%) had severe kidney injury requiring dialysis.

Conclusion

A single-stage endo-/epicardial CA resulted in favorable rhythm and symptom outcomes in a cohort of patients with symptomatic persistent/longstanding-persistent AF and one or more prior endocardial procedures. Epicardial ablation of BB was commonly implicated in procedural success.

SUBMITTER: De Martino G

PROVIDER: S-EPMC8457187 | biostudies-literature | 2021 Aug

REPOSITORIES: biostudies-literature

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Publications

Stepwise endo-/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach.

De Martino Giuseppe G Compagnucci Paolo P Mancusi Carmine C Vassallo Enrico E Calvanese Claudia C Della Ratta Giuseppe G Librera Mariateresa M Franciulli Marco M Marino Luigi L Russo Antonio Dello AD Casella Michela M

Journal of cardiovascular electrophysiology 20210712 8

<h4>Background</h4>Outcomes of catheter ablation (CA) among patients with nonparoxysmal atrial fibrillation (AF) are largely disappointing.<h4>Objective</h4>We sought to evaluate the feasibility, effectiveness, and safety of a single-stage stepwise endo-/epicardial approach in patients with persistent/longstanding-persistent AF.<h4>Methods</h4>We enrolled 25 consecutive patients with symptomatic persistent (n = 4) or longstanding-persistent (n = 21) AF and at least one prior endocardial procedur ...[more]

PMID: 34216076

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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.

Project description:Abstract Background Epicardial adipose tissue (EAT) has been considered as one of the probable triggers of atrial fibrillation (AF). CT‐rediomics is a perspective noninvasive method of assessment of EAT. We evaluate the radiomic phenotype of EAT in patients with lone AF in the prognosis of AF recurrence after catheter ablation. Methods A total of 43 patients with lone AF referred for CA and 20 out‐hospital patients without arrhythmia underwent multidetector computed tomography coronary angiography. Segmentation of EAT and extraction radiomic features were performed on calcium scoring series using by 3D‐Slicer. Clinical follow‐up was performed for 12 months period after the CA. Results EAT in patients with lone AF had a distinct radiomic phenotype. Thus, 45 of 93 calculated radiomic features, volume and attenuation of EAT were significantly different between patients with lone AF and persons without any arrhythmia. In addition, 17 radiomic features were significantly different in subgroups with and without AF recurrence. Multivariate regression analysis demonstrated that only gray level nonuniformity normalized (GLSZM) was an independent predictor of AF recurrence (OR 1.0027, 95%CI 1.0009–1.0044, p = 0.002). ROC analysis data showed that GLSZM >1227.4 indicates high probability of AF recurrence during 12 months (sensitivity 89.4%, specificity 70.8%, AUC: 0.809; p = 0.001). Conclusion The radiomic parameter GLSZM is associated with late AF recurrence after CA in patients with lone AF. In current study GLSZM was a stronger predictor of lone AF recurrence in multivariate analysis comparing with other established risk factors and EAT volume and attenuation. This study is a step forward towards the application of radiomic analisys for study the role of epicardial adipose tissue in the occurrence of AF recurrence after ablation. The results are significantly important due to the fact it was shown that the radiomic parameter GLSZM is associated with late AF recurrence after CA in patients without structural changes of myocardium. Moreover, GLSZM was the stronger predictor of isolated AF recurrence in multivariate analysis comparing with other established risk factors and EAT volume and attenuation.

Project description:AF is a heterogeneous rhythm disorder that is related to a wide spectrum of etiologies and has broad clinical presentations. Mechanisms underlying AF are complex and remain incompletely understood despite extensive research. They associate interactions between triggers, substrate and modulators including ionic and anatomic remodeling, genetic predisposition and neuro-humoral contributors. The pulmonary veins play a key role in the pathogenesis of AF and their isolation is associated to high rates of AF freedom in patients with paroxysmal AF. However, ablation of persistent AF remains less effective, mainly limited by the difficulty to identify the sources sustaining AF. Many theories were advanced to explain the perpetuation of this form of AF, ranging from a single localized focal and reentrant source to diffuse bi-atrial multiple wavelets. Translating these mechanisms to the clinical practice remains challenging and limited by the spatio-temporal resolution of the mapping techniques. AF is driven by focal or reentrant activities that are initially clustered in a relatively limited atrial surface then disseminate everywhere in both atria. Evidence for structural remodeling, mainly represented by atrial fibrosis suggests that reentrant activities using anatomical substrate are the key mechanism sustaining AF. These reentries can be endocardial, epicardial, and intramural which makes them less accessible for mapping and for ablation. Subsequently, early interventions before irreversible remodeling are of major importance. Circumferential pulmonary vein isolation remains the cornerstone of the treatment of AF, regardless of the AF form and of the AF duration. No ablation strategy consistently demonstrated superiority to pulmonary vein isolation in preventing long term recurrences of atrial arrhythmias. Further research that allows accurate identification of the mechanisms underlying AF and efficient ablation should improve the results of PsAF ablation.

Dataset Information

Stepwise endo-/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach.

Background

Objective

Methods

Results

Conclusion

Publications

Stepwise endo-/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach.

Similar Datasets

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