Techniques for curative treatment of atrial fibrillation.
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Atrial Fibrillation↗
Biomedical subjects
Pierre Jaïs
Publications and source records attributed to Pierre Jaïs.
Images in cardiovascular medicine. Early appearance of an edematous tissue reaction during left atrial linear ablation using intracardiac echo imaging.
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Cardiomyopathies↗
Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses.
BACKGROUND: Symptomatic prolonged sinus pauses on termination of atrial fibrillation (AF) are an indication for pacemaker implantation. We evaluated sinus node function and clinical outcome in patients with prolonged sinus pauses on termination of arrhythmia who underwent ablation of paroxysmal AF. METHODS AND RESULTS: Twenty patients with paroxysmal AF and prolonged sinus pauses (> or =3 seconds) on termination of AF underwent ablation between May 1995 and November 2002. Patients with sinus pauses independent of episodes of AF were excluded from the analysis. The procedure included pulmonary vein and linear atrial ablation. After ablation, sinus node function was assessed during the first week and at 1, 3, and 6 months, by 24-hour ambulatory monitoring to determine the mean heart rate and heart rate range, and by exercise testing to determine the maximal heart rate. Corrected sinus node recovery time was determined at the completion of ablation and at 24.0+/-11.3 months at 600 and 400 ms. After AF ablation, there was a significant improvement of sinus node function, with an increase in the mean heart rate (P=0.001), maximal heart rate (P<0.0001), and heart rate range (P<0.0001). The corrected sinus node recovery time decreased in all patients evaluated at 600 ms (P=0.016) and 400 ms (P=0.019). At 26.0+/-17.6 months, 18 patients (85%) had no recurrence of AF (in the absence of medication), with no symptoms attributable to bradycardia or sinus pauses on ambulatory monitoring. Two patients had infrequent episodes of AF, 1 requiring pacemaker implantation. CONCLUSIONS: Prolonged sinus pauses after paroxysms of AF may result from depression of sinus node function that can be eliminated by curative ablation of AF. This is accompanied by improvement in parameters of sinus node function, suggesting reverse remodeling of the sinus node.
Atrial Fibrillation↗
Mapping and ablation of ventricular fibrillation associated with long-QT and Brugada syndromes.
BACKGROUND: The long-QT and Brugada syndromes are important substrates of malignant ventricular arrhythmia. The feasibility of mapping and ablation of ventricular arrhythmias in these conditions has not been reported. METHODS AND RESULTS: Seven patients (4 men; age, 38+/-7 years; 4 with long-QT and 3 with Brugada syndrome) with episodes of ventricular fibrillation or polymorphic ventricular tachycardia and frequent isolated or repetitive premature beats were studied. These premature beats were observed to trigger ventricular arrhythmias and were localized by mapping the earliest endocardial activity. In 4 patients, premature beats originated from the peripheral right (1 Brugada) or left (3 long-QT) Purkinje conducting system and were associated with variable Purkinje-to-muscle conduction times (30 to 110 ms). In the remaining 3 patients, premature beats originated from the right ventricular outflow tract, being 25 to 40 ms ahead of the QRS. The accuracy of mapping was confirmed by acute elimination of premature beats after 12+/-6 minutes of radiofrequency applications. During a follow-up of 17+/-17 months using ambulatory monitoring and defibrillator memory interrogation, no patients had recurrence of symptomatic ventricular arrhythmia but 1 had persistent premature beats. CONCLUSIONS: Triggers from the Purkinje arborization or the right ventricular outflow tract have a crucial role in initiating ventricular fibrillation associated with the long-QT and Brugada syndromes. These can be eliminated by focal radiofrequency ablation.
Adult↗
Catheter Ablation of Ventricular Fibrillation in Structurally Normal Hearts Targeting the RVOT and Purkinje Ectopy.
Catheter ablation for ventricular fibrillation in structurally normal hearts is in its infancy. Recently, catheter ablation of idiopathic ventricular fibrillation as well as ventricular fibrillation associated with the long QT and Brugada syndromes has been described. This review article is a summary of our current understanding of the technique and results of catheter ablation of ventricular fibrillation in structurally normal hearts.
Adolescent↗
Comparison of permanent left ventricular and biventricular pacing in patients with heart failure and chronic atrial fibrillation: a prospective hemodynamic study.
BACKGROUND: Left ventricular pacing (LVP) and biventricular pacing (BVP) have been proposed as treatments for patients with advanced heart failure complicated by discoordinate contraction due to intraventricular conduction delay. For patients in sinus rhythm, BVP works in part by modulating the electronic atrial-ventricular time delay and thus optimizing contractile synchrony, the contribution of atrial systole, and reducing mitral regurgitation. However, little is known of the mechanisms of BVP in heart failure patients with drug-resistant chronic atrial fibrillation. HYPOTHESIS AND METHODS: LVP differs from BVP because hemodynamic and clinical improvement occurs in association with prolongation rather than shortening of the QRS duration. We sought to determine if LVP or BVP improves mechanical synchronization in the presence of atrial fibrillation. Thirteen patients with chronic atrial fibrillation, severe heart failure and QRS >or=140 ms received (after His bundle ablation) a pacemaker providing both LVP and BVP. The mean age was 62 +/- 6 years and left ventricular ejection fraction was 24 +/- 8%. After a baseline phase of one month with right ventricular pacing, all patients underwent in random order 2 phases of 2 months (LVP and BVP). At the end of each phase, an echocardiogram, a hemodynamic analysis at rest and during a 6-minute walking test and a cardio-pulmonary exercise test were performed. RESULTS: LVP and BVP provided similar performances at rest (p = ns). The 6-minute walking test revealed similar performances in both pacing modes but patients were significantly more symptomatic at the end of the test with LVP ( p = 0.035). The cardio-pulmonary exercise test showed higher performances with BVP (92 +/- 34 Watts) vs. LVP (77 +/- 23; p = 0.03). LVP was associated with significantly more premature ventricular complexes recorded during the 6 minute walking test (49 +/- 71) than BVP (10 +/- 23; p = 0.04). CONCLUSIONS: In this small series of patients with atrial fibrillation, congestive heart failure and a prolonged QRS duration, LVP and BVP provided similar hemodynamic effects at rest whereas BVP was associated with better hemodynamic effects during exercise and fewer premature ventricular complexes. Although the mechanisms for the observed differences are uncertain, it is possible that there is worsening of right ventricular function due to a rise in left-to-right electromechanical delay during exercise. Increased catecholamines release might contribute to the lower exercise tolerance and greater number of premature ventricular complexes recorded during exercise observed during LVP compared to BVP. RECOMMENDATIONS: Patients with atrial fibrillation, heart failure and QRS prolongation who are candidates for His-bundle ablation and cardiac resynchronization therapy may respond better to BVP rather than to LVP.
Atrial Fibrillation↗
Optical mapping technique applied to biventricular pacing: potential mechanisms of ventricular arrhythmias occurrence.
Although it has been suggested that multisite ventricular pacing alleviates heart failure by restoring ventricular electrical synchronization, the respective roles of voltage output, interventricular delay, and pacing sites in the development of ventricular arrhythmias occurrence have not been studied during biventricular pacing or LV pacing. Voltage-sensitive dye was used in eight ischemic Langerdorff-perfused guinea pig hearts to measure ventricular activation times and examine conduction patterns during multisite pacing from three RV and four LV sites. The hearts were stained with di-4-ANEPPS and mapped with a 16 x 16 photodiode array at a resolution of 625 microns per diode. Isochronal maps of RV and LV activation were plotted. Ischemia was produced by gradually halving the perfusion output over 5 minutes. Pacing the RV apex and the base of the LV anterior wall was associated with the most homogeneous and rapid activation pattern (28 +/- 9 vs 41 +/- 12 ms with the other configurations, P < 0.01), and no inducible arrhythmia. In six hearts, ventricular tachycardia could be induced when pacing from the right and left free walls with 20 ms of interventricular delay, at six times the pacing threshold output. In four hearts, simultaneous RV and LV pacing at high voltage output induced ventricular fibrillation with complex three-dimensional propagation patterns, independently of the pacing sites. During biventricular pacing with ischemia, pacing at high voltage output with a long interventricular delay is likely to induce ventricular arrhythmias, particularly when left and right pacing results in a conduction pattern orthogonal to the ventricular myocardial fibers orientation.
Animals↗
Cost analysis of catheter ablation for paroxysmal atrial fibrillation.
RF ablation for paroxysmal atrial fibrillation (PAF) is a curative treatment, which when successful, eliminates the need to take antiarrhythmic drugs, be anticoagulated, and have recurrent physician visits or hospital admissions. The authors performed a retrospective cost comparison of RF ablation versus drug therapy for PAF. The study population consisted of 118 consecutive patients with symptomatic, drug refractory PAF who underwent 1.52 +/- 0.71 RF ablation procedures (range 1-4) for PAF. During a follow-up of 32 +/- 15 weeks, 85 (72%) patients remained free of clinical recurrence in absence of antiarrhythmic drugs. The cost of RF ablation was calculated in the year 2001 euros on the basis of resource use. The mean cost of pharmacologic treatment prior to ablation was 1,590 euros/patient per year. The initial cost of RF ablation for PAF was 4,715 euros, then 445 euros/year. After 5 years, the cost of RF ablation was below that of ongoing medical management, and continued to diverge thereafter. RF catheter ablation may be a cost-effective alternative to long-term drug therapy in patients with symptomatic, drug refractory PAF.
Anti-Arrhythmia Agents↗
Electrophysiologically guided pulmonary vein isolation during sustained atrial fibrillation.
INTRODUCTION: Sustained atrial fibrillation (AF) is frequently encountered during pulmonary vein (PV) isolation. The aim of this study was to evaluate the feasibility and safety of PV isolation during sustained AF. METHODS AND RESULTS: Thirty-seven patients (30 men, age 54 +/- 10 years) underwent Lasso-guided isolation of 87 PVs during sustained AF. Baseline PV electrogram patterns were classified into one of two types: organized, with consistent PV activation sequence; or disorganized, with constant variation of PV activation sequence. In disorganized activity, radiofrequency ablation was performed circumferentially around the Lasso while the earliest PV potential was targeted during organized activity. Complete left atrial (LA) to PV block during AF was identified by abolition or dissociation of all sharp potentials recorded within the vein. PV isolation then was verified during sinus rhythm. Baseline activation patterns of PV potential were organized in 32 PVs (37%) [more frequently in inferior veins than superior veins (53% vs 26%, P = 0.01)] and disorganized in 55 PVs (63%). In 59 of 87 PVs, isolation was begun and completed during AF. Radiofrequency ablation organized PV activation sequence in 75% prior to isolation. LA-PV block was confirmed during sinus rhythm in 54 (92%) of 59 PVs. In 28 of 87 PVs, sinus rhythm was restored before complete LA-PV block. Complete isolation was achieved in all 87 PVs without complications. CONCLUSION: PV isolation can be effectively and safely performed during sustained AF, preceded in most cases by organization of PV electrogram activity. This strategy may be the preferred alternative to multiple intraprocedural cardioversions.
Adult↗
Dissociated pulmonary vein arrhythmia: incidence and characteristics.
INTRODUCTION: The incidence and characteristics of dissociated arrhythmia confined to the pulmonary vein (PV) following disconnection have not been described in a large number of patients with paroxysmal atrial fibrillation. METHODS AND RESULTS: This was a prospective study of 152 patients (29 female, mean age 51 +/- 11 years) referred for catheter ablation of drug-refractory paroxysmal atrial fibrillation. Following ostial ablation, the rate and regularity of any dissociated venous activity was analyzed with and without isoproterenol infusion (to achieve a heart rate of 120-140 beats/min). Patients then were classified according to their venous dissociated activity. Group 1 consisted of patients in whom the dissociated PV spike had a slow rhythm >1,200 ms. Group 2 consisted of patients with spontaneous repetitive dissociated discharges confined in the vein with a cycle length <400 ms. A total of 384 PVs were ablated in 152 patients. Disappearance of all venous potentials was observed in 88% of the treated veins; at least one dissociated venous potential was observed in the remaining 12%. Group 1 activity was seen more often than group 2 (23 patients, mean cycle length 2,300 +/- 1,100 ms vs 13 patients, mean cycle length 179 +/- 77 ms). Dissociated PV arrhythmia was seen most often in the right superior PV (19%). CONCLUSION: Dissociation as the endpoint of PV disconnection was observed in 12% of PVs. Due to the capricious nature of this activity, the actual incidence is almost certainly higher. The dissociated venous rhythm usually is slow and, less commonly, is rapid and repetitive.
Adult↗
Pulmonary vein disconnection using the LocaLisa three-dimensional nonfluoroscopic catheter imaging system.
INTRODUCTION: Catheter ablation for atrial fibrillation (AF) is associated with prolonged fluoroscopy times. We prospectively evaluated the use of the LocaLisa three-dimensional nonfluoroscopic catheter imaging system with the aim of reducing fluoroscopy times during pulmonary vein (PV) disconnection. METHODS AND RESULTS: Fifty-two patients with AF (47 men and 5 women, mean age 53 +/- 9 years) underwent disconnection of all four PVs guided by a circumferential mapping catheter. The LocaLisa navigation system was used for real-time three-dimensional nonfluoroscopic imaging of the circumferential mapping catheter and ablation catheter electrodes in 26 patients. Procedural parameters were compared with those of a control group consisting of 26 patients in whom only standard fluoroscopy was used. PV disconnection was performed similarly in both groups by circumferential ablation around the ostia, with the endpoint of disconnecting left atrium to PV breakthroughs. The cumulative duration of radiofrequency (RF) energy delivery, procedural time, and fluoroscopy time required for PV disconnection were compared. Successful disconnection was achieved in all PVs, without acute complications. There was no significant difference in cumulative RF energy delivery: 34.8 +/- 11.4 minutes for the nonfluoroscopic imaging group versus 38.2 +/- 10.5 minutes for the control group. The fluoroscopy time required for disconnection of all four PVs was significantly lower in the LocaLisa group than in the control group: 8.4 +/- 4.3 minutes versus 23.7 +/- 9.7 minutes (P < 0.0001). There also was a significant difference in the mean time taken for PV disconnection: 46.5 +/- 12.0 minutes for the nonfluoroscopic imaging group versus 66.3 +/- 18.9 minutes for the control group (P < 0.0001). CONCLUSION: By allowing continuous three-dimensional monitoring of ablation and mapping catheter position and orientation, the LocaLisa nonfluoroscopic imaging system significantly reduces fluoroscopy and PV disconnection times.
Atrial Fibrillation↗
The inferior vena cava: an exceptional source of atrial fibrillation.
Mapping in a patient undergoing radiofrequency ablation for drug-refractory paroxysmal atrial fibrillation in the setting of repetitive, monomorphic atrial ectopic beats with negative p waves in the inferior leads revealed an arrhythmogenic focus located in the posteromedial inferior vena cava (IVC) 1 cm below the right atrium to IVC junction. The focus was mapped using a Lasso catheter with successful irrigated-tip catheter ablation at the site of earliest activity. This case demonstrates that, in rare cases, arrhythmogenic muscular sleeves can be found in the IVC and that the IVC can be electrically disconnected from the right atrium using radiofrequency energy.
Adult↗
Transcardiac pericardiocentesis: an emergency life-saving technique for cardiac tamponade.
Life-threatening cardiac tamponade is one of the most serious complications of catheter-based cardiac procedures. Although most cases can be effectively treated by percutaneous pericardiocentesis, urgent surgical drainage is required in unsuccessful cases. Rarely, in collapsed patients, the delay for surgery, however minimal, may be fatal. We describe a technique whereby life-saving pericardial drainage was rapidly achieved via a novel transcardiac approach, using the transseptal puncture kit, after failure of conventional pericardiocentesis in a patient with procedure-related acute tamponade who rapidly deteriorated and developed cardiorespiratory arrest within a few minutes. Although surgical repair for the perforation had to be performed subsequently, the patient survived without sequelae. This transcardiac approach may be an important and potentially life-saving adjunctive technique after failure of conventional pericardiocentesis in rapidly deteriorating or extremely unstable patients.
Aged↗
Distinctive electrophysiological properties of pulmonary veins in patients with atrial fibrillation.
BACKGROUND: Atrial fibrillation (AF) is frequently initiated from pulmonary veins (PVs), but little is known of the electrophysiological properties of PVs. METHODS AND RESULTS: Two groups were studied: 28 patients (49+/-13 years old) with paroxysmal AF and 20 control patients (49+/-14 years old) without AF. Effective and functional refractory period and conduction time from PV to left atrium (LA) were compared in the 2 groups by use of programmed stimulation with a single extrastimulus in the PVs and LA. In the AF group, the venous effective refractory periods (ERPs) were shorter than that of the LA: 185+/-71 versus 253+/-21 ms, P<0.001, whereas in the control group, they were longer (282+/-45 versus 253+/-41 ms, P=0.009). The venous ERPs and functional refractory periods in patients with AF were also shorter than that observed in control subjects (185+/-71 versus 282+/-45 ms and 210+/-77 versus 315+/-43 ms, respectively, P<0.001), whereas LA ERPs were not significantly different. Decremental conduction in PVs was more frequent (93% versus 56%, P=0.01) and had a greater increment (102+/-65 versus 42+/-40 ms, P<0.001) in patients with AF. Finally, AF was more frequently induced when pacing was performed in PVs (22 of 90) versus LA (1 of 81) in patients with AF (P<0.001). CONCLUSIONS: The PVs of patients with AF exhibited distinctive electrophysiological properties, which were strikingly different from those of patients devoid of AF, potentially explaining their arrhythmogenicity.
Adult↗
Mapping and ablation of idiopathic ventricular fibrillation.
BACKGROUND: Ventricular fibrillation is the main mechanism of sudden cardiac death. The feasibility of eliminating recurrent episodes by catheter ablation has not been reported. METHODS AND RESULTS: Twenty-seven patients without known heart disease (13 men, 14 women, 41+/-14 years of age) were studied after being resuscitated from recurrent (10+/-12) episodes of primary idiopathic ventricular fibrillation; 23 had received a defibrillator. The first initiating beat of ventricular fibrillation had an identical electrocardiographic morphology and coupling interval (297+/-41 ms) to preceding isolated premature beats typically noted in the aftermath of resuscitation. These triggers were localized by mapping the earliest electrical activity and ablated by local radiofrequency delivery. Outcome was assessed by Holter and defibrillator memory interrogation. Premature beats were elicited from the Purkinje conducting system in 23 patients: from the left ventricular septum in 10, from the anterior right ventricle in 9, and from both in 4. The interval from the Purkinje potential to the following myocardial activation varied from 10 to 150 ms during premature beat but was 11+/-5 ms during sinus rhythm, indicating location at peripheral Purkinje arborization. The premature beats originated from the right ventricular outflow tract muscle in 4 patients. The accuracy of mapping was confirmed by acute elimination of premature beats during local radiofrequency delivery. During a follow-up of 24+/-28 months, 24 patients (89%) had no recurrence of ventricular fibrillation without drug. CONCLUSIONS: Primary idiopathic ventricular fibrillation is a syndrome characterized by dominant triggers from the distal Purkinje system. These sources can be eliminated by focal energy delivery.
Adult↗
[Ablative methods for atrial fibrillation].
Surgery and catheter-based ablation are the only curative approaches of atrial fibrillation. Since 1994, several ablative techniques based on 2 different concepts have been developed: modification of the substrate with long linear lesions to prevent fibrillation maintenance; and foci ablation to prevent fibrillation initiations. The latter is more frequently used now as the clustering of foci in pulmonary veins allows their isolation. The presence of numerous foci in some patients is responsible for more complex procedures and limits the success rate to 70%. In spite of this limit and because of a reasonable complication rate, this procedure compares favourably to His bundle ablation in young patients with symptomatic and drug-resistant paroxysmal atrial fibrillation.
Atrial Fibrillation↗
Electrical conduction in canine pulmonary veins: electrophysiological and anatomic correlation.
BACKGROUND: Paroxysmal atrial fibrillation in patients is often initiated by foci in the pulmonary veins. The mechanism of these initiating arrhythmias is unknown. The aim of this study was to determine electrophysiological characteristics of canine pulmonary veins that may predispose to initiating arrhythmias. METHODS AND RESULTS: Extracellular recordings were obtained from the luminal side of 9 pulmonary veins in 6 Langendorff-perfused dog hearts after the veins were incised from the severed end to the ostium. Pulmonary veins were paced at the distal end, the ostium, and an intermediate site. During basic and premature stimulation, extracellular electrical activity was recorded with a grid electrode that harbored 247 electrode terminals. In 4 hearts, intracellular electrograms were recorded with microelectrodes. Myocyte arrangement immediately beneath the venous walls was determined by histological analysis in 3 hearts. Extracellular mapping revealed slow and complex conduction in all pulmonary veins. Activation delay after premature stimulation could be as long as 96 ms over a distance of 3 mm. Action potential duration was shorter at the distal end of the veins than at the orifice. No evidence for automaticity or triggered activity was found. Histological investigation revealed complex arrangements of myocardial fibers that often showed abrupt changes in fiber direction and short fibers arranged in mixed direction. CONCLUSIONS: Zones of activation delay were observed in canine pulmonary veins and correlated with abrupt changes in fascicle orientation. This architecture of muscular sleeves in the pulmonary veins may facilitate reentry and arrhythmias associated with ectopic activity.
Action Potentials↗
Electrogram polarity reversal as an additional indicator of breakthroughs from the left atrium to the pulmonary veins.
OBJECTIVES: We assessed the anatomical distribution and electrogram characteristics of breakthrough from the left atrium (LA) to the pulmonary veins (PVs). BACKGROUND: Localization of LA-PV breakthrough is an important technique for PV ablation in patients with atrial fibrillation (AF). METHODS: A total of 157 patients with paroxysmal AF underwent PV disconnection guided by mapping with a circumferential 10-electrode catheter. Radiofrequency (RF) current was delivered ostially at the site(s) of earliest activation (113 patients) or electrogram polarity reversal defined by opposite polarity across adjacent bipoles (44 patients). Breakthrough sites were proved by changes in pulmonary vein potential activation sequence occurring as a result of localized RF delivery and were classified into four segments around the ostium (top, bottom, anterior, posterior). Results of mapping and ablation were compared between the two groups. RESULTS: A total of 99% of 411 targeted PVs were successfully disconnected in both groups. Breakthroughs were most frequent at the bottom of superior PVs (85% prevalence) and the top of inferior PVs (75% prevalence). A wide activation front (>5 synchronous bipoles) indicating broad breakthrough was observed in 18% of PVs. Polarity reversal occurred with 88% sensitivity and 91% specificity at breakthrough sites. Polarity reversal was restricted to fewer bipoles (2.0 +/- 0.4 bipoles vs. 3.4 +/- 2.0 bipoles, p < 0.01) compared with earliest activation. Shorter RF application time was required to disconnect PVs with wide synchronous activation using polarity reversal compared with using conventional earliest activity (10.3 +/- 3.0 min vs. 12.3 +/- 3.4 min, p < 0.05). CONCLUSIONS: Bipolar electrogram polarity reversal allows more precise localization of breakthrough compared with the earliest activation, particularly in cases of wide synchronous PV activation.
Adult↗