Left Atrial Flutter Research Articles

Радиочастотная аблация атипичного левопредсердного трепетания после изоляции устьев легочных вен

Радиочастотная аблация атипичного левопредсердного трепетания после изоляции устьев легочных вен

Atrial tachycardias occurring late after open heart surgery.

Atrial tachycardias are common after open heart surgery. Most commonly these are macro-reentrant including cavotricuspid isthmus dependent atrial flutter, incisional right atrial flutter and left atrial flutter. Focal atrial tachycardias occur less frequently. The specific type of atrial tachycardia highly depends on the type of surgical incision. Catheter ablation can be very effective, however requires a thorough understanding of anatomy and surgical technique.

Comparison of Safety of Left Atrial Catheter Ablation Procedures for Atrial Arrhythmias Under Continuous Anticoagulation With Apixaban Versus Phenprocoumon

Apixaban is increasingly used for stroke prevention in patients with atrial fibrillation. Data about the safety of left atrial radiofrequency ablation procedures under continuous apixaban therapy are lacking. We performed a matched-cohort study of patients undergoing left atrium ablation procedures for atrial fibrillation or left atrial flutter. For each patient on apixaban, 2 patients on phenprocoumon were matched by age, gender, and type of arrhythmia. The primary safety end point was a composite of bleeding, thromboembolic events, and death. We identified 105 consecutive patients (35 women; mean age 63years) on apixaban and matched 210 phenprocoumon patients (70 women, mean age 64years). The primary end point was met in 11 patients of the apixaban group and 26 patients of the phenprocoumon group (10.5% vs 12.3%, p= 0.71). Major bleeding complications occurred in 1 patient of the apixaban group and 1 patient of the phenprocoumon group (1% vs 0.5%, p >0.99). Minor bleeding complications were observed in 10 patients of the apixaban group and 25 patients of the phenprocoumon group (9.5% vs 11.9%, p= 0.61). No patient in either group experienced a thromboembolic event and no patient died. In patients on apixaban, no clinical variable was predictive for bleeding complications. Left atrial ablation procedures under continuous oral anticoagulation with apixaban are feasible and as safe as under continuous oral anticoagulation with phenprocoumon.

Utility of intracardiac echocardiography for catheter ablation of complex cardiac arrhythmias in a medium-volume training center.

New electrophysiology tools like intracardiac echocardiography (ICE) might help to minimize and early detect complications during cardiac ablation procedures. The aim of the study was to assess the utility and vascular safety of ICE during catheter ablation of complex cardiac arrhythmias in a medium-volume training center. Prospective, observational study consisted of consecutive patients who underwent catheter-based ablation of complex cardiac arrhythmias. All procedures were performed using three-dimensional electro-anatomical mapping and routine cannulation of right and left femoral veins. The ICE probe was initially positioned at the mid-level of the right atrium and properly moved to monitor different steps of the procedure and identify complications. All procedure-related vascular complications were registered. One hundred two patients (age 61.4 ± 13.1 years, 69 male) underwent 110 ablation procedures. Pulmonary vein isolation was the most common ablation substrate (55.4%). Ventricular tachycardia (17.2%) and left atrial flutter procedures (16.4%) were also common. The use of ICE enabled us to early initiate anticoagulation and to optimize the transseptal puncture. It also provided the capability to early detect life-threatening complications such as tamponade (3.6%), along with important information during the procedure such as exact catheter location, lesion formation, and stability during radiofrequency delivery. Such benefits were not associated with a higher number of vascular complications. The use of ICE during catheter-based ablation of complex cardiac substrates provides technical features that may decrease complications and increase accuracy while applying radiofrequency, especially in training centers where fellows start to perform complex procedures.

Postablation scar-related atrial tachycardia: turning the spotlight on P-wave analysis and window settings.

Left atrial flutter (AFL) and localized scar-related atrial tachycardia (AT) are the most common tachyarrhythmias that follow catheter or surgical ablation for atrial fibrillation. Three-dimensional activation mapping can be challenging due to large and often multiple areas of scar interspersed with areas of delayed conduction, resulting in complex reentrant circuits.1 In our experience, there are 3 components of mapping that are crucial to localizing the re-entry circuit and guiding catheter ablation: (1) analysis of the P wave on surface ECG, (2) right and left atrial (LA) intracardiac activation sequence from multielectrode catheters positioned at the right atrium (RA; 20 poles) and proximal coronary sinus (CS; 10 poles; Figure 1A), and (3) careful attention to the mapping window settings based on P-wave analysis and the cycle length of the tachycardia. Figure 1. A , Right anterior oblique (RAO) and left anterior oblique (LAO) fluoroscopic projections with duodecapolar catheter with 2-10-2 mm spacing placed in the right atrium (RA) at the tricuspid annular and a decapolar catheter with 2-5-2 mm spacing placed in the proximal coronary sinus (CS). B1 , Counter clockwise tricuspid annular atrial flutter (CCW-TA-AFL) with correlation of RA activation and P wave in leads V1, II, III, and aVF. B2 , Counter clockwise mitral annular atrial flutter (CCW-MA-AFL) with simultaneous atrial activation in the RA and CS and earliest RA activation at 9 to 10 pair electrodes indicating early RA activation at the high RA septum. The shallow upsloping portion in leads II, III, and aVF is much earlier than the P-wave onset in V1. B3 , CW-MA-AFL with early RA activation located at the low or mid septum, propagating to high and low RA with atrial activation in the proximal CS preceding the lateral atrial activation of RA. C , Activation mapping of the RA during CCW-TA-AFL. The atrial …

Radiofrequency ablation of left atrial flutter mediated with double potentials in a seemingly normally structured heart

BackgroundLeft atrial flutter (left AFL) is common in patients who undergo atrial fibrillation ablation and cardiac surgery; however, few reports describe left AFL in detail in a seemingly normally structured heart, and the mechanisms of the occurrence of such arrhythmia are still not clear. We describe left AFL in patients without prior cardiac surgery or catheter ablation and discuss the electrophysiological characteristics that may explain the preferential generation and perpetuation of such tachycardia. Methods and resultsEleven patients with left AFL, who had no history of cardiac surgery or interventions, underwent electrophysiological studies and 3-dimensional electroanatomic mapping studies. Echocardiography revealed a relatively mild dilation of the left atrium, mild to moderate mitral regurgitation, and a normal left ventricular ejection fraction. The electroanatomic mapping during tachycardia showed a “reentrant” activation pattern in all patients. The mean tachycardia cycle length was 266±17ms. A single-loop reentrant circuit was identified in 7 patients. A counterclockwise left atrial flutter evolved around the mitral valve annulus in 6 patients. The tachycardia rotated around the left atrial anterior wall in 1 patient. Four patients exhibited a double-loop reentrant circuit with a “figure of 8” pattern reentry. Double potentials as the critical isthmus of the circuit were identified in the left atrial anterior wall near the mitral annulus which displayed a low-voltage area matched with the left atrium–aorta contiguity. The conduction velocity was significantly slower in the double-potential recording area than in the lateral mitral annulus (0.36±0.03m/s vs 0.74±0.12m/s; P<0.05). Successful ablation around the double-potential recording site caused an interruption of the tachycardia, and remained free of recurrence during a 12-month follow-up in all patients. ConclusionLeft AFL in patients without a history of surgery or ablation is rarely observed in clinical practice. The successful site of ablation was within the anterior wall near the mitral annulus showing the double potentials as the critical part of the reentrant circuit. This suggests that perhaps a double potential-targeted ablation may be effective for these patients.

Catheter Ablation of Atrial Arrhythmias in Cardiac Sarcoidosis

We previously reported on the incidence and clinical implications of supraventricular arrhythmia in patients with cardiac sarcoidosis (CS). The role of catheter ablation for the management of atrial arrhythmia (AA) in this patient population is unknown. One hundred consecutive patients with CS were monitored for the incidence of supraventricular arrhythmias. Those with persistent symptoms despite optimal medical therapy proceeded to catheter ablation. Following ablation, all patients were followed serially with Holter monitoring or device interrogation. Thirty-two (32%) patients had symptomatic supraventricular arrhythmias. Nine (28%) patients had symptomatic AA requiring catheter ablation for clinical indications. Mean age was 55 ± 11.6 years. Five (56%) patients had atrial fibrillation (AF), of whom 2 also had cavotricuspid isthmus ablation. Four patients had isolated atrial flutter: 2 patients with left atrial flutter, and 2 patients with cavotricuspid flutter. All other arrhythmias were ablated in the left atrium. Mean duration of follow-up was 1.8 ± 1.9 years. One patient with atypical atrial flutter, and one patient with AF have had recurrence; the remaining patients remain in sinus rhythm. Our study suggests that AA in CS is frequently left atrial in origin. Catheter ablation appears to be effective and safe for the maintenance of sinus rhythm in patients with CS.

THE COMPARISON OF ARRHYTHMOGENICITY OF DIFFERENT SURGICAL APPROACHES TO ATRIAL FIBRILLATION IN PATIENTS WITH CORONARY HEART DISEASE

Aim. To estimate the prevalence of iatrogenic atrial flutter in patients with coronary heart disease (CHD) and atrial fibrillation (AF) after two types of surgical operations: radiofrequency pulmonary veins isolation and radiofrequency modified mini Maze procedure; and to compare the results with control group of patients undergone aortic-coronary bypass grafting (CABG).Material and methods. Totally 95 patients included with CHD and persistent AF. Subjects were randomized into three groups: 1st (n=31) — with simultaneous CABG and radiofrequency ablation of pulmonary veins ostiums; 2nd (n=30) — simultaneous CABG and mini Maze procedure; 3rd control (n=34) — CABG only. For prolonged ECG monitoring the implanted devices Reveal XT were used in 53 subjects.Results. The patients escaped from left-atrial flutter were 90% in the 1st group. In the 2nd there was 1 case of left-atrial flutter (according to electrophysiological investigation — the leap through the mitral valve line), meaning 96,9% patients free from it. However there was no significant difference between 1st and 2nd groups (p=0,6). In the 3rd group postprocedure flutter developed in one case too, due to the scar on the left atrium wall after mitral valve regurgitation correction; so 97% patients escaped from flutter, but the difference was still not significant (p=0,4).Conclusion. In patients with CHD and AF it is recommended to perform radiofrequency modified mini Maze procedure combined with CABG due to its lower proarrhythmogenic effect. The rate of iatrogenic flutter is 3,1% after mini Maze and 10% after pulmonary veins ostiums isolation.

Catheter ablation of atrial fibrillation and left atrial flutter in a patient with a left atrial appendage occlusion device

A 60-year-old woman with atrial fibrillation (AF) and prior implantation of an Amplatzer Cardiac Plug (ACP) left atrial appendage (LAA) occlusion device was referred for ablation. A pre-procedural transoesophageal echocardiography revealed device deformation of the anterior aspect of the left superior pulmonary vein …

Rotors of truly atypical atrial flutters visualized by FIRM mapping and 3D-MRI overlay on live fluoroscopy

Rotors of two different left atrial flutters were mapped using focal impulse and rotor modulation and 3D-MRI overlayed on live fluoroscopy and were successfully ablated in a patient with two prior left-atrium ablation procedures for recurrent atrial fibrillation.

Hammock mitral valve as a cause of atrial flutter: Three months old infant case

Hammock mitral valve is a very rare congenital valve disorder It may lead to mitral stenosis or insufficiency in the pediatric age group These patients generally present with the symptoms of congestive heart failure or sometimes sudden death may occur Our case was a 3 month old female infant who presented to our clinic with the symptoms of heart failure Her cardiac evaluation revealed hammock mitral valve left atrial dilatation severe mitral valve insufficiency and atrial flutter In contrast to adult patients atrial flutter is a very rare type of cardiac aryhtmia in the pediatric age group We present this case because no such case with atrial flutter resulting from hammock mitral valve has been reported in the literature Turk Arch Ped 2013; 48: 244 247

Ganglionated plexi ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/longstanding persistent atrial fibrillation: a randomized comparison

Introduction: The optimal ablation technique for persistent and longstanding persistent Atrial Fibrillation (AF) is unclear. Both Linear Lesions (LL) and Ganglionated Plexi (GP) ablation have been used, in addition to Pulmonary Vein Isolation (PVI), but no direct comparison of the two methods exists. Methods: Two hundred sixty four consecutive patients with persistent/longstanding persistent AF were randomly assigned to 2 different ablation schemes: PVI+LL (n=132) and PVI+GP ablation (n=132). Consistent Sinus Rhythm (SR) off antiarrhythmic drug was assessed after follow-up of at least 3 years with the use of an implanted monitoring device (IMD). Results: All procedural endpoints were acutely achieved. At 12 months following a single procedure, 47% of patients treated with PVI+LL were in SR compared to 54% of patients treated with PVI+GP (p=0.29). At 3 years, 34% of patients with PVI+LL and 49% of patients with PVI+GP maintained SR (p=0.035). Atrial flutter was more frequent in PVI+LL than in PVI+GP ablation group (18% versus 6%, P=0.002). After a second procedure in 78 patients of the PVI+LL group and 55 patients of the PVI+GP group, the long-term overall success rate was 52% and 68%, respectively (p=0.006). Conclusions: PVI+GP ablation confers superior clinical results with less ablation-related left atrial flutter and reduced AF recurrence compared to PVI+LL at 3 years of follow-up.

GW24-e2233 Mapping, verification and ablation of the recurrence left atrial polycyclic reentry atrial flutter after ablation of persistent atrial fibrillation

ObjectivesIntroduce the method of mapping, verification and ablation the recurrence left atrial polycyclic reentry atrial flutter (AFL) after ablation of persistent atrial fibrillation (PsAF).Methods14 patients (9 men) with left atrial...

Continuous warfarin versus periprocedural dabigatran to reduce stroke and systemic embolism in patients undergoing catheter ablation for atrial fibrillation or left atrial flutter

Left atrial catheter ablation for patients with atrial fibrillation (AF) requires periprocedural anticoagulation to minimize thromboembolic complications. High rates of major bleeding complications using dabigatran etexilate for periprocedural anticoagulation have been reported, raising concerns regarding its safety during left atrial catheter ablation. We sought to evaluate the safety and efficacy of a dabigatran use strategy versus warfarin, at a single high-volume AF ablation center. We performed a retrospective analysis on consecutive patients undergoing left atrial ablation at Vanderbilt Medical Center from January 2011 through August 2012 with a minimum follow-up of 3months. Patient cohorts were divided into two groups, those utilizing dabigatran etexilate pre- and post-ablation and those undergoing ablation on dose-adjusted warfarin, with or without low-molecular-weight heparin bridging. Dabigatran was held 24-30h pre-procedure and restarted 4-6h after hemostasis was achieved. We evaluated all thromboembolic and bleeding complications at 3months post-ablation. A total of 254 patients underwent left atrial catheter ablation for atrial fibrillation or left atrial flutter. Periprocedural anticoagulation utilized dabigatran in 122 patients and warfarin in 135 patients. Three late thromboembolic complications occurred in the dabigatran group (2.5%), compared with one (0.7%) in the warfarin group (p = 0.28). The dabigatran group had similar minor bleeding (2.5 vs. 7.4%, p = 0.07), major bleeding (1.6 vs. 0.7%, p = 0.51), and composite of bleeding and thromboembolic complications (6.6 vs. 8.9%, p = 0.49) when compared to warfarin. There were no acute thromboembolic complications in either group (<24h post-ablation). In patients undergoing left atrial catheter ablation for AF or left atrial flutter, use of periprocedural dabigatran etexilate provides a safe and effective anticoagulation strategy compared to warfarin. A prospective randomized study is warranted.

Ganglionated plexus ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/long-standing persistent atrial fibrillation: A randomized comparison

The optimal ablation technique for persistent and long-standing persistent atrial fibrillation (AF) is unclear. Both linear lesion (LL) and ganglionated plexus (GP) ablation have been used in addition to pulmonary vein isolation (PVI), but no direct comparison of the 2 methods exists. The aim of this study is to assess the comparative safety and efficacy of 2 different ablation strategies-PVI+LL vs PVI+GP ablation -in patients with persistent or long-standing persistent AF. Two hundred sixty-four consecutive patients with persistent/long-standing persistent AF were randomly assigned to 2 different ablation schemes: PVI+LL (n = 132) and PVI+GP (n = 132) ablation. Consistent sinus rhythm (SR) off antiarrhythmic drug was assessed after follow-up of at least 3 years with the use of an implanted monitoring device. All procedural end points were acutely achieved. At 12 months after a single procedure, 47% of the patients treated with PVI+LL were in SR compared to 54% of the patients treated with PVI+GP (P = .29). At 3 years, 34% of the patients with PVI+LL and 49% of the patients with PVI+GP maintained SR (P = .035). Atrial flutter was more frequent in the PVI+LL group than in PVI+GP group (18% vs 6%; P = .002). After a second procedure in 78 patients of the PVI+LL group and 55 patients of the PVI+GP group, the long-term overall success rate was 52% and 68%, respectively (P = .006). PVI+GP ablation confers superior clinical results with less ablation-related left atrial flutter and reduced AF recurrence compared to PVI+LL ablation at 3 years of follow-up.

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

211: Left atrial flutter occurring after atrial fibrillation ablation: ablation using remote magnetic navigation versus manual technique

Limited data exist on the efficacy and safety of remote magnetic navigation (RMN) ablation of iatrogenic left atrial flutter (LAF) occurring after atrial fibrillation (AF) ablation. LAF ablation procedures (proc) were reviewed. Patients (pts) were divided into 2 groups (gr): RMN gr if proc were performed remotely using the Niobe system (Sterotaxis) and conventional gr (CON) if proc were performed with manually driven catheters. Open-irrigated 3.5 mm-tip catheters were used in all pts. Activation LA maps were realized in all pts using Carto or EnSite). Acute (defined as sinus rhythm- SR- resumption during ablation) and long-term (defined as SR maintenance) proc success, proc duration, fluoroscopy and radiofrequency (RF) times, and the mechanism of arrhythmias were studied. In 46 pts (38 males, 60.8±10.19 y) 57 LAF ablation proc were performed. Age and LA size were similar. Activation maps showed: a unique macro-reentrant circuit 46%, multiples successive macro-reentrant circuits 26%, focal pulmonary vein tachycardia 9%, micro-reentrant circuit 19%. Results are showed in the table. Complications occurred in 3 proc: 1 in the RMN gr (groin hematoma) and 2 in the CON gr (1 transient ischemic attack and 1 cardiac perforation with tamponade). Perimitral flutter that occurred at any stage of the proc was associated with significantly higher rate of acute failure (persistent perimitral flutter at the end of the proc, both gr): 44% vs 12% for other types of flutter, p=0.02. RMN (n= 25) CON (n= 32) p Acute success 80% 78% 0.86 Proc/pt 1.2±0.5 1.2±0.8 0.74 Long-term success (follow-up 12.5±11.3 months) 81% 66% 0.44 Fluoroscopy 748±377 s 1086±772 s 0.05 Proc time 236±68 min 201±72 min 0.06 RF time 1291±880 s 1181±897 s 0.70 As compared to manual proc, RMN guided ablation for LAF after AF ablation provides comparable acute and long-term success rate but is potentially safer.

208: Midterm follow-up of patients with paroxysmal and persistent atrial fibrillation after pulmonary vein isolation by cryoballoon ablation

The objective of this prospective study was to evaluate the midterm clinical outcomes of PV isolation, using a cryoballoon catheter in our center. Between july 2006 and november 2011, 234 consecutive patients (age 56±11 years, 76% of men) with symptomatic paroxysmal (n =162) or persistent AF (n =72) underwent PV isolation with a 28 mm or 23 mm cryoballoon catheter. In case of AF reccurence, patients could have several procedures using cryoablation and/or PV isolation and additional linear lesions by radiofrequency. Follow-up with holter monitoring and phone calls were performed. We successfully isolated 713 of 936 PV (76%). In 73 patients (31%), an irrigated-tip radiofrequency catheter was used to create a supplemental focal lesion after cryoapplication and 55 patients (24%) had cavo-tricuspid isthmus line. 28 mm cryoballoon catheter was mostly used (141 procedures, 60%). The mean overall procedural duration was 178±36 min (range 120-285), and mean duration of fluoroscopic exposure was 9±5 min (range 3-27). Over a median period of 20 months (range 3-53), 12 patients were lost to follow-up, 4 patients were deceased. At 3 months of follow-up, 78% of patients with paroxysmal AF had remained recurrence free, vs. 69% of patients with persistent AF. Phrenic nerve palsy was the most frequent, although reversible complication. A left atrial flutter appeared in 23 cases (11%). Considering midterm outcomes, 68% of patients with paroxysmal AF and 62% of patients with persistent AF had no recurrence, after an average of 1.3 procedures. Looking at failures, only 10% of patients did not have any improvement after ablation. 52% of patients were free of AF without antiarrhythmic drugs and 36% of them had stopped anticoagulation. PV isolation, using a cryoballoon catheter is a safe and effective strategy with a high rate of success. It can be an alternative to RF ablation but randomised comparisons are needed.

Macroreentrant Atrial Tachycardia in Patients without Previous Atrial Surgery or Catheter Ablation: Clinical and Electrophysiological Characteristics of Scar‐Related Left Atrial Anterior Wall Reentry

Macroreentrant atrial tachycardia (MRAT) has been described most frequently in patients with prior cardiac surgery. Left atrial tachycardia and flutter are common in patients who undergo atrial fibrillation ablation; however, few reports describe left atrial MRAT involving the regions of spontaneous scarring. Here, we describe left atrial MRAT in patients without prior cardiac surgery or catheter ablation (CA) and discuss the clinical and electrophysiological characteristics of tachycardia and outcome of CA. An electrophysiological study and CA were performed in 6 patients (3 men; age 76 ± 6 years) with MRAT originating from the left atrial anterior wall (LAAW). No patient had a history of cardiac surgery or CA in the left atrium. Spontaneous scars (areas with bipolar voltage ≤ 0.05 mV) were observed in all patients. The activation map showed a figure-eight circuit with loops around the mitral annulus (4 counterclockwise and 2 clockwise) and a low-voltage area with LAAW scarring. The mean tachycardia cycle length was 303 ± 49 milliseconds. The conduction velocity was significantly slower in the isthmus between the scar in the LAAW and the mitral annulus than in the lateral mitral annulus (0.17 ± 0.05 m/s vs 0.94 ± 0.35 m/s; P = 0.003). Successful ablation of the isthmus caused interruption of the tachycardia and rendered it noninducible in all patients. Spontaneous LAAW scarring is an unusual cause of MRAT, showing activation patterns with a figure-eight configuration. Radiofrequency CA is a feasible and effective treatment in such cases.