Pulmonary Vein Ostia Research Articles

P1908Left common pulmonary vein in atrial fibrillation ablation with cryoballoon. A meta-analysis

Abstract Background Conflicting results regarding the impact of left common pulmonary (LCPV) vein on clinical outcome of atrial fibrillation (AF) ablation with cryoballoon technology have been reported. In the present study, we sought to investigate the performance of the 28 mm cryoballoon advance (CB-A) on left common pulmonary vein (LCPV) in terms of post procedural outcome. Methods We systematically searched on PubMed and Cochrane library for the articles that compared the recurrence rate of AF after cryoballoon ablation between patients with four separate and distinct pulmonary vein ostia and with LCPV. Results A total of 5 studies with 1052 patients met our predefined inclusion criteria. Recurrence of AF after CB-A ablation was similar in both groups (Log OR 0.45; 95% CI: −0.03, 0.94; I=48%, p=0.08), Fig 1. Figure 1 Conclusion LCPV doesn't affect clinical outcome of AF ablation with cryoballoon technology.

P984Residual gaps in the ablation line and requirement for carina ablation during contact force-guided radiofrequency pulmonary vein isolation: determinants and prognostic implications

Abstract Background Pulmonary vein isolation (PVI) is not always achieved after initial encircling of the pulmonary veins (PVs). Additional touch-up lesions are frequently required to close residual gaps, which may occur both in the initial ablation line and on the intervenous carina. Purpose We aimed to identify determinants and prognostic implications of residual gaps during index radiofrequency PVI. Methods Two hundred fourteen AF (atrial fibrillation) patients (57% paroxysmal, 61% male, mean age 62±9 years) undergoing contact force-guided PVI were studied. Residual gaps after initial encircling of the PVs were targeted for additional ablation and were classified as either gap ablation in the initial WACA (wide-area circumferential ablation) circle or carina ablation, depending on the site of earliest activation. After a waiting period of at least 30 minutes, persistence of PVI was tested through administration of 9–18 mg intravenous adenosine. Pre-procedural cardiac computed tomography imaging was used to assess left atrial and PV anatomy. Carina width was defined as the distance between ipsilateral superior and inferior PV ostia. Ablation procedures were analyzed to define the perimeter of the WACA circle. Results One hundred thirty-three patients (62%) required additional ablation lesions beyond the initial WACA circles to achieve complete PVI. Gap ablation was required in the left WACA circle in 34 patients (16%) and in the right WACA circle in 49 patients (23%). Left and right carina ablation were required in 50 (23%) and 83 (39%) patients, respectively. Multivariate analyses identified carina width and perimeter of the WACA circle as independent predictors of requirement for ipsilateral carina ablation, whereas paroxysmal AF and the perimeter of the WACA circle were associated with requirement of gap ablation in the initial WACA circle. Recurrence of atrial tachyarrhythmias was documented in 73 patients (34%) at 12 months follow-up. Kaplan–Meier survival analyses demonstrated a significantly higher rate of recurrence in patients with one or more residual gaps in the ablation line (43% vs. 30%, p=0.019, figure A), whereas no significant difference between patients with and without requirement of carina ablation was found (38% and 29%, respectively; p=0.111, figure B). Kaplan-Meier survival analyses Conclusion Residual gaps in the initial WACA circle were associated with increased AF recurrence rate after PVI, whereas residual gaps on the intervenous carina had no statistically significant impact on AF recurrence. Consequently, gaps occurring in the ablation line and gaps on the intervenous carina may represent different mechanisms and may have different prognostic implications.

Acute enhancement of necrotic radio-frequency ablation lesions in left atrium and pulmonary vein ostia in swine model with non-contrast-enhanced T1 -weighted MRI.

To evaluate non-contrast-enhanced MRI of acute radio-frequency ablation (RFA) lesions in the left atrium (LA) and pulmonary vein (PV) ostia. The goal is to provide a method for discrimination between necrotic (permanent) lesions and reversible injury, which is associated with recurrence after treatment of atrial fibrillation. Fifteen normal swine underwent RFA around the right-superior PV ostia. Electrical pulmonary vein isolation (PVI) was verified by electro-anatomic mapping (EAM) and pacing. MRI was carried out using a 3D respiratory-gated T1 -weighted long inversion time (TWILITE) sequence without contrast agent. Key settings were: inversion time 700 ms, triggering over 2 cardiac cycles, pixel size 1.1 mm3 . Contrast-enhanced imaging and T2 -weighted imaging were carried out for comparison. Six animals were sacrificed on ablation day for TTC-stained gross pathology, 9 animals were sacrificed after 2-3 mo after repeat EAM and MRI. Image intensity ratio (IIR) was used to measure lesion enhancement, and gross pathology was used to validate image enhancement patterns and compare lesion widths. RFA lesions exhibited unambiguous enhancement in acute TWILITE imaging (IIR = 2.34 ± 0.49 at 1.5T), and the enhancement patterns corresponded well with gross pathology. Lesion widths in MRI correlated well with gross pathology (R2 = 0.84), with slight underestimation by 0.9 ± 0.5 mm. Lesion enhancement subsided chronically. TWILITE imaging allowed acute detection of permanent RFA lesions in swine LA and PV ostia, without the need for contrast agent. Lesion enhancement pattern showed good correspondence to gross pathology and was well visualized by volume rendering. This method may provide valuable intra- or post-procedural assessment of RFA treatment.

Intermediate term outcome after electrogram guided segmental ostial pulmonary vein isolation using an 8 mm tip catheter for paroxysmal atrial fibrillation

IntroductionPulmonary vein isolation (PVI) is the most widely used procedure for ablation in patients with paroxysmal atrial fibrillation (AF). Not withstanding recent advancements in this field, including sophisticated three-dimensional (3D) based imaging and advanced ablation catheters with contact force technology, many patients and healthcare systems in developing countries will not afford such an expensive therapeutic procedure. There are no data from India analyzing the efficacy of PVI for PAF using conventional mapping and ablation. In this article, we have summarized the intermediate term outcome following PVI in patients with PAF using electrogram-based mapping and a 8 mm tip ablation catheter. MethodA total of 42 consecutive patients who underwent PVI for symptomatic PAF not controlled with at least one antiarrhythmic drug were studied in a tertiary care institute from March 2011 to June 2018. Patients with rheumatic AF were excluded. The pulmonary vein (PV) anatomy was assessed by pulmonary angiography during the ablation procedure. Using conventional electrophysiologic mapping, a variable curve Lasso catheter placed in the PVs was used to guide the earliest site of breakthrough. The segmental ostial PVI was performed using a 8 mm tip radiofrequency (RF) ablation catheter. Elimination of all PV ostial potentials and complete entrance block into the PV were considered indicative of complete electrical isolation. Follow-up visits were scheduled at one, three, and six months after the procedure, and every six months thereafter. History, symptom review, clinical examination, and 12-lead ECG were performed at each follow-up. ResultsAt pre-discharge, 34 patients (81%) were in sinus rhythm, while eight patients (19%) continued to have atrial fibrillation. The age of the study population was 51.5 ± 11.7 yrs. The mean follow-up duration was 44 ± 21 months (range 6–84 months). The number of PVs isolated included one (five patients, 11.9%), two (20 patients, 47.6%), three (12 patients, 28.6%), and four (five patients, 11.9%). In 42 patients, a total of 101 PVs were isolated. The right superior PV (RSPV) was isolated in 37 patients, the left superior PV (LSPV) was isolated in 39 patients, the left inferior PV (LIPV) was isolated in 14 patients, and the right inferior PV (RIPV) was isolated in six patients. The procedure duration was 125 ± 29 min and the fluoroscopy time was 47 ± 13 min. The number of patients who remained in sinus rhythm at 1, 6, 12, and 24 months were 34 (81%), 32 (76%), 30 (71%), and 26 (62%), respectively. Two patients of these underwent repeat PVI, which was successful, and they had freedom from AF episodes. Complications were rare. One patient had a minor pericardial effusion, and one patient had transient sinus pauses, which were conservatively managed. ConclusionConventional RF ablation using PV potential-based mapping and ablation with 8 mm tip catheters is safe for patients with PAF. The intermediate term outcome is satisfactory and cost-effective in our setting with limited resources.

Predictors of sustained isolation of pulmonary vein ostia with cryoballoon ablation using a second-generation cryoballoon Arctic Front Advance

Aim. To determine the electrophysiological and biophysical predictors of sustained isolation of pulmonary vein (PV) ostia, affecting the immediate and longterm results of interventional treatment of atrial fibrillation (AF) using cryoballoon ablation (CBA) with the second-generation cryoballoon Arctic Front Advance. Material and methods. The analysis included 143 PV in 37 patients with a paro-xysmal/persistent form of AF, which, after the primary CBA with the use of the second-generation cryoballoon, carried out additional interventions due to recurrence of AF and/or combined arrhythmia. During the primary CBA, the registration of biophysical and electrophysiological parameters of the procedure was performed. During the ablation in the right PV from the diagnostic electrode installed in the superior vena cava, the ipsilateral phrenic nerve was stimulated (2000 ms, 25 mA). When the phrenic nerve response to stimulation was decreased/disappeared, ablation ceased instantly. At the end of the procedure, isolation control of the PV was performed. A repeat/additional procedure was performed for the recurrence of AF and/or documented combined arrhythmia no earlier than 3 months after the initial ablation. The stability of the LV isolation was assessed using a circular mapping technique. According to the results of mapping, drugs were divided into 2 groups: isolated and with recurrent activity. Results. The frequency of sustained isolation of PV was 67,8%. Recurrent spike activity was recorded in 46 PV (32,2%). Higher frequency of registration of electrical isolation of PV in real time (68% vs 50%, p=0,001), stability of occlusion with a cryoballoon (85,5% vs 69,5%, p=0,024), low values of the minimum cryoballoon temperatures reached (49,2±6,3 vs 44,0±4,9, p<0,0001) and less need for additional applications (8,3% vs 34,7%, p<0,0001) were registered in the group of chronic isolation of PV. Multi-factor analysis of these parameters confirmed the predictor role of the minimum cryoballoon temperature. According to the ROC analysis, the threshold minimum temperature was 45,5° C with a sensitivity of 68% and a specificity of 60,9%. Conclusion. Cryoballoon isolation of PV ostia is an effective and safe method for achieving chronic isolation of PV. The minimum cryoballoon temperature with a threshold value of <-45,5° C is an independent predictor of long-term isolation of PV.

Searching for the Key to Foreseeing Left Atrial Fibrosis in Atrial Fibrillation: Could This Be Simple and Reliable with MRI?

Searching for the Key to Foreseeing Left Atrial Fibrosis in Atrial Fibrillation: Could This Be Simple and Reliable with MRI?

Early Tissue Reaction After Second-Generation Cryoballoon Ablation Evaluated with Intracardiac Echocardiography.

Radiofrequency energy applications immediately produce tissue edema. This study aimed to investigate the acute tissue reaction immediately after second-generation cryoballoon applications using 3-dimensional intracardiac echocardiography (ICE) imaging technology.This study consisted of 10 patients with paroxysmal atrial fibrillation who underwent pulmonary vein isolation (PVI) using second-generation cryoballoons. Ablation was performed with a single 3-minute freeze strategy and exclusively 28-mm balloons. The left atrial and right pulmonary vein (PV) antra geometries were created with 3-dimensional ICE technology before and immediately after the PVI.Out of 20 right PVs, 19 were isolated exclusively with cryoballoons, and one right inferior PV (RIPV) required touch-up ablation. All 10 right superior PVs (RSPVs) were isolated by single cryoballoon applications, and RIPVs were isolated by a mean of 1.2 ± 0.4 applications. The total application time was 171 ± 19 and 203 ± 71 seconds, and nadir balloon temperature was -56.0 ± 4.9 and -53.8 ± 5.4°C for the RSPVs and RIPVs, respectively. In all patients, diffuse wall thickening of the antra and ostium of the right PVs was observed as compared to baseline. The wall thickening was 0-0.25 mm in 3 patients, and 0.25-0.5 mm in the remaining 7. During the median follow-up of 13 [10.2-17.2] months, 8 (80%) patients were free from arrhythmia recurrences. Nine (90%) patients underwent repeat cardiac computed tomography at a median of 6.0 [4.5-12.0] months after the initial procedure, and no PV stenosis was observed in all.Tissue edema and wall thickening appeared in the human left atrium immediately after second-generation cryoballoon ablation.

SEVEN TYPES OF PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA IN ONE PATIENT

The report describes the case of electrophysiological study and catheter ablation of seven types of supraventricular tachycardia in one patient. During radiofrequency ablation for WPW-syndrome three functionated discrete retrograde conductive accessory atrioventricular pathways were documented and were successfully ablated. Further incessant activity of two ectopic atrial focuses was revealed. First localized in upper part of crista terminalis and another – in left superior pulmonary vein ostium. Five months after patient had a recurrence of supraventricular tachycardia. EPI-study demonstrated evidence for retrograde ventriculoatrial dissociation with induction of atypical fast/slow and typical slow/fast atrioventricular nodal reentry tachycardia, wich were successfully ablated. With further observation, rhythm disturbances did not recur.

Morphology and morphometry of pulmonary veins and the left atrium in multi-slice computed tomography

PurposePulmonary veins are involved in pathogenesis and treatment of atrial fibrillation and structures at risk during thoracic surgeries. There is lack of data regarding pulmonary vein morphology and morphometry in normal population.MethodsThe study was conducted using 135 chest computed tomography studies with intra-venous iodine contrast injection. The study population contained 86 females and 49 males, mean age was 60. 13 had atrial fibrillation. The studies were analyzed using radiological workstation.ResultsMean dimensions of the left atrium: transverse 52 mm, coronal 49 mm, and sagittal 35 mm. The mean volume of the left atrium was 93 cm3. The mean volume of the left atrium in patients with atrial fibrillation was 176 cm3. The sagittal dimension and the volume of the left atrium were correlated with age, r = 0.43 and r = 0.42, respectively. Surface area of the left inferior pulmonary vein ostium was 136 mm2, significantly less than the surface area of other ostia of pulmonary veins. The mean distance between two pulmonary veins was 5.42 mm on the right and 4.02 mm on the left side. 13 types of pulmonary veins outflow patterns were described on the right side and 5 types on the left side. 66.7% of right pulmonary veins and 82% of the left pulmonary veins emptied into the left atrium with two venous trunks on each side (the typical pattern).ConclusionsMorphological features of pulmonary veins and morphometry of the left atrium and pulmonary veins are important for clinical purposes and are in accordance with previous papers.

Initial Result of Antrum Pulmonary Vein Isolation Using the RadiofrequencyHot-Balloon Catheter WithSingle-ShotTechnique.

This study sought to determine the feasibility of a novel simplified ablation protocol targeting only the pulmonary vein antrum using the radiofrequency hot-balloon catheter in patients with paroxysmal atrial fibrillation. Radiofrequency hot-balloon (RHB) catheter has been recently introduced into clinical practice for pulmonary vein isolation (PVI). The authors hypothesized that a novel simplified ablation protocol targeting only the PV antrum with energy application for a longer time (single-shot technique) could be an alternative approach to achieve PVI, while avoiding unnecessary energy application at the PV ostium. A total of 61 consecutive paroxysmal atrial fibrillation patients (age 64.1 ± 10.9 years, 48 male) who underwentantrum RHB-PVI were enrolled. Energy applications were performed following the pre-specified protocol only targeting the PV antrum. If the PVI was not achieved after 2 energy applications using the RHB, a touch-up ablation was performed. Of 241 PV, including 3 left common PV, 194 (80%) were isolated exclusively using the RHB. The target PVI average per group of 15 consecutive procedures improved from 75% (initial 15) to 89% (last 16) of patients. The injected volume was greatest in the right superior PV (13.1 ± 2.0 ml) and the smallest in the left inferior PV (10.8 ± 1.1 ml), and 23 PV (9.5%) required over 15 ml (estimated balloon diameter of 30 mm). Periprocedural complications were noted in 3 patients (4.9%), but phrenic nerve injury was not observed. Sinus rhythm maintenance at 12-month follow-up was achieved in 57 patients (93%). A novel simplified antrum RHB-PVI appears to be a feasible technique for the treatment of paroxysmal atrial fibrillation.

Analysis of the anatomical features of pulmonary veins on pre-procedural cardiac CT images resulting in incomplete cryoballoon ablation for atrial fibrillation

BackgroundTo investigate the anatomical features related to the failure of cryoballoon (CB) ablation for atrial fibrillation (AF) on pre-procedural CT images. MethodsWe retrospectively analyzed CT images of 100 patients with AF who had undergone a first CB ablation at our institution between June 2016 and April 2017. We measured the angle, short- and long axis length, and the area and ovality of 4 major pulmonary vein (PV) ostium on CT images. We performed logistic regression analysis to analyze the anatomical features related to the failure (incomplete CB ablation) of PV isolation. We also performed a receiver-operating characteristic (ROC) curve analysis to identify an appropriate cut-off value for anatomical features significantly associated with incomplete CB ablation. ResultsWe analyzed 400 PVs in 100 patients [aged 64 (range, 27–82) years, 59% male]. The rate of incomplete CB ablation was significantly higher for right-than left-sided PVs (p < 0.001). The anatomical feature significantly associated with incomplete CB ablation was the angle at the right inferior PV (RIPV) (AOR: 1.17; 95% CI: 1.09–1.27, p < 0.001) and the right superior PV (RSPV) (AOR: 1.12; 95% CI: 1.01–1.23; p = 0.014). In the ROC analysis, the optimal cut-off value for RIPV and RSPV angle to discriminate an incomplete CB ablation were 40.1° and 79.7°, respectively. ConclusionOur findings may help to select the appropriate ablation strategy to treat patients with AF. We show that the angle is an anatomical feature significantly related to failed CB ablation.

64-multidetector CT anatomical assessment of the feline bronchial and pulmonary vascular structures

The aim of the study was to provide a detailed anatomical study of the feline bronchial and vascular structures by using CT angiography (CTA). Adult cats with no respiratory clinical signs were enrolled in a CTA protocol to provide an anatomical study of the thorax. The dimensions, number of branches and branching pattern (monopodial vs dichotomic) of both bronchial and pulmonary vascular structures were evaluated under positive inspiration apnoea. A linear generalised estimating equations analysis (Spearman's rho) was used to identify statistical correlation between tracheal diameter, age and body weight of the cats. Fourteen cats met the inclusion criteria. The pulmonary arteries had larger diameters than the pulmonary veins, and the pulmonary veins had larger diameters than the bronchial structures. A higher number of segmental bronchial and pulmonary vascular branches was observed in the left caudal lung lobe than in the other lobes. The monopodial branching pattern of both bronchial and pulmonary vascular structures was predominant in all cats of our study (100%) in cranial, caudal and right middle lung lobes, while a dichotomic branching pattern of the bronchial and pulmonary vascular structures of the accessory lung lobe was seen in 13 cats (93%). Thirteen cats (93%) had three pulmonary vein ostia, and one cat (7%) also presented with an additional left intermediate pulmonary vein ostium. Variation in the number of segmental pulmonary vein branches was noted in the right caudal lung lobe. There was no statistical correlation between tracheal diameter, age and weight. Architecture of the feline bronchovascularr structures belongs to a mixed type of monopodial and dichotomic branching pattern. In cats, the pulmonary venous drainage system predominately presents three pulmonary vein ostia. Variations in the type of formation and the number of branches of the pulmonary venous drainage system were noted.

Unipolar electrogram-guided radiofrequency catheter ablation in paroxysmal atrial fibrillation: electrogram patterns and outcomes.

Transmural lesions (TLs) are the crucial point for radiofrequency catheter ablation (RFCA) in atrial fibrillation (AF) patients. Previous studies have reported that complete positive unipolar electrogram (UP-EGM) after ablation is associated with transmural lesions. However, UP-EGM patterns may differ in different regions of continuous circular lesions (CCLs) around the pulmonary vein ostia after ablation. We aimed to analyze the different UP-EGM patterns in different CCL regions after ablation and the effectiveness of UP-EGM guided RFCA in paroxysmal atrial fibrillation (PAF). A total of 43 patients with PAF (aged 59 ± 11years; 65% male) were consecutively included. Pulmonary vein isolation was achieved by contiguous point-by-point RFCA. UP-EGM was recorded by the ablation catheter. Both CCLs were divided into six regions. Two points were randomly chosen from each region to analyze UP-EGM type after ablation. All the patients were followed for atrial arrhythmias recurrence. All pulmonary veins were isolated with complete bidirectional block. A total of 1032 RFCA points with complete positive UP-EGM were collected. UP-EGM morphology after ablation was divided into four different types defined as R, rR', Rr', and M. M patterns mostly appeared in anterosuperior (65%) and roof (49%) regions of left CCLs. In the remaining regions, the percentage of non-M patterns (R, rR', and Rr') ranged from 63% in posteroinferior regions of right CCLs to 88% in anteroinferior regions of right CCLs. After a mean follow-up time of 19months, 37 (86%) patients remained in sinus rhythm. Most (72%) UP-EGM types after ablation are non-M patterns. Pulmonary vein isolation guided by UP-EGM with a complete positive pattern in PAF patients is reliable.

Mapping of atrial fibrillation: strategies to understand an enigmatic arrhythmia.

The three-dimensional (3D) mapping of cardiac arrhythmias has evolved in recent years to an important and extremely useful tool, providing important insights into arrhythmia mechanisms and thus improving ablation success rates, especially in complex arrhythmias. In atrial fibrillation (AF), the most common but also one of the most complex cardiac arrhythmias, progress in mapping technology has been focusing on several aspects according to the type of AF.In paroxysmal AF, important progress in the exact anatomic reconstruction of the main ablation target, i.e., the pulmonary veins (PV), has been achieved. Perhaps even more importantly, new insights into conduction patterns, such as deceleration at the PV ostia, spiral conduction more distally into the PV, and PV cross-talk have been detected and enable faster and more sustainable PV isolation.In persistent AF, the basic understanding of ongoing AF is perhaps the electrophysiological challenge of the 21st century. Since AF is instable in its course, mapping tools that assess statistically returning patterns or deal with so-called AF "rotors" or "drivers" have been developed, offering unique insights into possible AF mechanisms. Refined high-density bi-atrial voltage maps make it possible to further characterize the arrhythmogenic substrate and scar zones, while new and innovative mapping algorithms enable automated, fast, and reliable annotation of up to thousands of electrograms.This improved understanding of AF mechanisms has led to the development of promising new ablation strategies, some of which are already in use in clinical routine.

Anatomical and procedural predictors of pulmonary vein stenosis in the setting of second-generation cryoballoon ablation.

Pulmonary vein stenosis (PVS) is a well recognized complication as a consequence of pulmonary vein isolation. In the current study, we sought to analyze potential anatomical and intraprocedural predictors of PVS during second-generation cryoballoon ablation, particularly focusing on the impact of freeze duration and number of cryoapplications. Fifty-four patients who underwent cryoballoon ablation for atrial fibrillation were included retrospectively in this study. All patients underwent cardiac-enhanced multidetector computed tomography both before and after the ablation. The exclusion criteria were any contraindications for the procedure, including the presence of an intracavitary thrombus, uncontrolled heart failure and contraindications to general anesthesia. Mild (25-50%) PVS was only detected in one vein (0.4%) and neither moderate (50-75%) nor severe (>75%) PVS were found. Twenty-five pulmonary veins (12%) exhibited slight narrowing of the diameter (less than 25%). In the univariate analysis, a longer duration of cryoapplication and a larger pulmonary vein ostium preprocedure diameter and area were independently associated with pulmonary vein narrowing [odds ratio (OR): 1.004; confidence interval (CI): 1.001-1.008, P = 0.016; OR: 1.250, CI: 1.090-1.434, P = 0.001 and OR: 1.006; CI: 1.002-1.011, P = 0.006] respectively. Longer duration of cryoablation, an increased number of applications per vein and larger pulmonary vein ostia are associated with a higher risk of pulmonary vein diameter and area reduction. These findings might suggest to lower the dosing to a single and shorter application if isolation is attained, to reduce the possibility of future pulmonary vein narrowing.

Differential Association of Cx37 and Cx40 Genetic Variants in Atrial Fibrillation with and without Underlying Structural Heart Disease.

Atrial fibrillation (AF) appears in the presence or absence of structural heart disease. The majority of foci causing AF are located near the ostia of pulmonary veins (PVs), where cardiomyocytes and vascular smooth muscle cells interdigitate. Connexins (Cx) form gap junction channels and participate in action potential propagation. Genetic variants in genes encoding Cx40 and Cx37 affect their expression or function and may contribute to PV arrhythmogenicity. DNA was obtained from 196 patients with drug-resistant, symptomatic AF with and without structural heart disease, who were referred for percutaneous catheter ablation. Eighty-nine controls were matched for age, gender, hypertension, and BMI. Genotyping of the Cx40 −44G > A, Cx40 +71A > G, Cx40 −26A > G, and Cx37 1019C > T polymorphisms was performed. The promoter A Cx40 polymorphisms (−44G > A and +71A > G) showed no association with non-structural or structural AF. Distribution of the Cx40 promoter B polymorphism (−26A > G) was different in structural AF when compared to controls (p = 0.03). There was no significant difference with non-structural AF (p = 0.50). The distribution of the Cx37 1019C > T polymorphism was different in non-structural AF (p = 0.03) but not in structural AF (p = 0.08) when compared to controls. Our study describes for the first time an association of drug-resistant non-structural heart disease AF with the Cx37 1019C > T gene polymorphism. We also confirmed the association of the Cx40 − 26G > A polymorphism in patients with AF and structural disease.

Primary, cardiac, fibroblastic osteosarcoma

Rationale:Primary cardiac osteosarcoma is a rare tumor. To our knowledge, only 15 cases have been reported in the literature in the past 10 years. We describe a case of primary, cardiac, fibroblastic osteosarcoma in a 42-year-old woman.Patient concerns:A 42-year-old woman with a 10-day history of chest pain. Intraoperatively, a mass was found originating from the ostium of the left inferior pulmonary vein in the left atrium, extending to the mitral orifice. Histologically, the tumor contained variable amounts of spindle cells and osseous differentiation in different areas. Primary, cardiac fibroblastic osteosarcoma had the typical appearance of interlacing hyperchromatic spindle-shaped stromal cells associated with osseous matrix.Diagnoses:According to the clinicopathological features, diagnosis of primary, cardiac fibroblastic osteosarcoma was made.Interventions:Wide surgical excision of the mass was performed.Outcomes:Three months after the operation, transthoracic echocardiography demonstrated a 3.2 cm × 2 cm recurrent mass in the wall of the left atrium (LA). She died shortly afterwards as a result of the local disease recurrence.Lessons:In this report, we describe a rare case of primary, cardiac fibroblastic osteosarcoma, and findings are helpful for the pathologists would like to further identify the clinicopathological features of this rare tumor.

A 3D imaging approach in the mouse to characterize congenital heart malformations and associated situs malpositions

The mouse model is widely used to assess the origin of congenital heart malformations because of similarities between the mouse and human heart. However, the small size of the mouse heart challenges the use of human imaging techniques. Here, we propose a novel imaging pipeline in the mouse to characterize congenital heart malformations and their potential association with situs malposition. Using Micro Computed Tomography, the position and asymmetric shape of internal organs can be extracted. We propose a list of anatomical differences between mouse and human internal organs (e.g.: common ostium of pulmonary veins). To gain higher resolution in the diagnosis of heart malformations we then use High Resolution Episcopic Microscopy on explanted hearts, which can resolve the left/right morphology of atria and ventricles ( Fig. 1 ). Alongside this high-resolution pipeline in fixed samples, we also use live imaging of embryonic hearts in utero, by echography, to correlate in the same heart, the embryonic shape with congenital heart malformations at birth. This strategy will be generally useful to analyze mouse mutants and provide novel insight into the mechanism of congenital heart defects.

Pulmonary Vein Anatomy is Associated with Cryo Kinetics during Cryoballoon Ablation for Atrial Fibrillation.

BackgroundThe influence of pulmonary vein (PV) anatomy on cryo kinetics during cryoballoon (CB) ablation is unclear.ObjectiveTo investigate the relationship between PV anatomy and cryo kinetics during CB ablation for atrial fibrillation (AF).MethodsSixty consecutive patients were enrolled. PV anatomy, including ostial diameters (long, short and corrected), ratio between short and long diameters, ostium shape (round, oval, triangular, and narrow), and drainage pattern (typical, with common trunk, common antrum, ostial branch and supernumerary PV) were evaluated on multi-detector computed tomography (MDCT) images pre-procedure. Cryo kinetics parameters [balloon freeze time from 0 to -30ºC (BFT), balloon nadir temperature (BNT) and balloon warming time from -30 to +15ºC (BWT)] were recorded during procedure. All p values are two-sided, with values of p < 0.05 considered to be statistically significant.Results606 times of freezing cycle were accomplished. Moderate negative correlation was documented between BNT and corrected PV diameter (r = -0.51, p < 0.001) when using 23-mm CBs, and mild negative correlation (r = - 0.32, p = 0.001) was found when using 28-mm CBs. Multivariate logistic regression analysis revealed that PV corrected ostial diameter (OR, 1.4; p = 0.004) predicted a BNT < -51ºC when using 23-mm CBs, while PV ostium oval shape (OR, 0.3; p = 0.033) and PV locations (left inferior PV: OR, 0.04; p = 0.005; right superior PV: OR, 4.3; p = 0.025) predicted BNT < -51ºC when using 28-mm CBs.ConclusionsMDCT can provide PV anatomy accurate evaluation prior CB ablation. PV anatomy is associated with cryo kinetics during ablation.

Common ostium of the left pulmonary veins – to freeze or not to freeze – that was the question?

Second-generation cryoballoon (CB2) - based pulmonary vein isolation (PVI) has demonstrated encouraging clinical results in the treatment of paroxysmal (PAF) and persistent atrial fibrillation (PersAF). Nevertheless, the acute efficacy, safety, and long-term clinical results of CB2-based PVI in patients with a left common pulmonary vein (LCPV) are still a matter of debate. Commented paper by Heeger ChH, et al. analyzes this issue with some practical conclusions.