Successful Catheter Ablation Research Articles

Prophylactic Cavotricuspid Isthmus Ablation in Atrial Fibrillation without Documented Typical Atrial Flutter: A Systematic Review and Meta-analysis.

Background: The advantage of prophylactic cavotricuspid isthmus (CTI) ablation for AF patients without documented atrial flutter is still unclear. The present study aimed to evaluate the role of prophylactic CTI ablation in this population. Methods: A systematic review and meta-analysis study was conducted. The overall effects estimation was conducted using random effects models. The pooled effects were presented as the risk difference and standardised mean difference for dichotomous and continuous outcomes, respectively. Results: A total of 1,476 patients from four studies were included. The risk of atrial tachyarrhythmias following a successful catheter ablation procedure was greater in the pulmonary vein isolation + CTI ablation group than pulmonary vein isolation alone group (34.8% versus 28.2%; risk difference 0.08; 95% CI [0.00–0.17]; p=0.04). Prophylactic CTI ablation was associated with a higher recurrent AF rate (33.8% versus 27.1%; risk difference 0.07; 95% CI [0.01–0.13]; p=0.02). Additional prophylactic CTI ablation to pulmonary vein isolation significantly increased the radio frequency application time (standardised mean difference 0.52; 95% CI [0.04–1.01]; p=0.03). Conclusion: This study suggested that prophylactic CTI ablation was an ineffective and inefficient approach in AF without documented typical atrial flutter patients.

P-Wave Beat-to-Beat Analysis to Predict Atrial Fibrillation Recurrence after Catheter Ablation.

The identification of patients prone to atrial fibrillation (AF) relapse after catheter ablation is essential for better patient selection and risk stratification. The current prospective cohort study aims to validate a novel P-wave index based on beat-to-beat (B2B) P-wave morphological and wavelet analysis designed to detect patients with low burden AF as a predictor of AF recurrence within a year after successful catheter ablation. From a total of 138 consecutive patients scheduled for AF ablation, 12-lead ECG and 10 min vectorcardiogram (VCG) recordings were obtained. Univariate analysis revealed that patients with higher B2B P-wave index had a two-fold risk for AF recurrence (HR: 2.35, 95% CI: 1.24–4.44, p: 0.010), along with prolonged P-wave, interatrial block, early AF recurrence, female gender, heart failure history, previous stroke, and CHA2DS2-VASc score. Multivariate analysis of assessable predictors before ablation revealed that B2B P-wave index, along with heart failure history and a history of previous stroke or transient ischemic attack, are independent predicting factors of atrial fibrillation recurrence. Further studies are needed to assess the predictive value of the B2B index with greater accuracy and evaluate a possible relationship with atrial substrate analysis.

Non-invasive localization of premature ventricular focus: A prospective multicenter study

BackgroundAccurate localization of premature ventricular contractions (PVC) focus is a prerequisite to successful catheter ablation. ObjectiveThe objective was to evaluate the software View Into Ventricular Onset (VIVO) accuracy at locating the anatomical origins for premature ventricular contractions. The VIVO device noninvasively creates a model of the patient's heart and torso, with exact locations of 12‑lead ECG electrodes, and applies a mathematical algorithm from surface signals to determine the origin of the arrhythmia. We sought to compare the agreement between VIVO-predicted locations to invasive electroanatomical mapping results. Methods51 consecutive patients who presented for PVC ablations at the study centers were recruited. VIVO images were collected at baseline preprocedure and all patients underwent invasive electroanatomical activation mapping of the clinical arrhythmia. Pacing was performed in pre-specified locations in the right and/or left ventricle. The successful sites of ablation and the pacing locations were compared to VIVO predicted locations. The results were adjudicated by physician experts in a blinded fashion. ResultsSeven patients were excluded from analyses. VIVO accurately identified the origin of the clinical premature ventricular contractions in 44/44 patients (100.00%). The accuracy in identifying the paced location for all patients (right and left sides of the heart) was 99.5% using the VIVO system. No adverse events were reported. ConclusionsVIVO is a novel noninvasive system that could be used to help guide ablation procedures with a high degree of accuracy. The VIVO algorithm is easy to use and may be useful in the workflow for ventricular arrhythmia ablation.

Result and technique consideration of radiofrequency catheter ablation of tachycardia in patients with dextrocardia

Patients with tachycardia, in the context of pre-existing dextrocardia, could benefit from catheter ablation. However, anatomical complexities hinder effective conduct of this procedure. We aimed to retrospectively summarize the clinical characteristics and the safety and efficiency, and recommended the technique considerations. Twenty-one cases from 19 patients with tachycardia and dextrocardia, who underwent catheter ablation between 2009 and 2021, were enrolled. All patients underwent echocardiography and computed tomography (CT) to confirm the anatomical malformations. Transseptal puncture was guided by fluoroscopy or intracardiac echocardiography when left atrial access was necessary and the ablation process was guided by three-dimensional (3D) mapping. Six cases exhibited situs solitus while nine cases exhibited situs inversus. Fourteen cases had atrial fibrillation, seven had atrial flutter, and two had atrioventricular reentrant tachycardia (AVRT); two cases had combined atrial fibrillation and atrial flutter. Acute success was achieved in 18 cases (85.7%, 18/21). The 3D mapping system was not employed in the three cases which failed. During long-term follow-up (20.71 ± 21.86 months), eight cases (72.7%, 8/11) of atrial fibrillation with dextrocardia successfully attained sinus rhythm. None of AVRT cases had recurrence. Half of the atrial flutter cases with dextrocardia, especially those with a history of surgical correction for cardiac malformations, underwent recurrence. One case had cardiac tamponade. Catheter ablation for tachycardia patients with dextrocardia is safe, efficient, and feasible. It is imperative to integrate echocardiography, cardiac computer tomography, and 3D mapping, and apply 3D reconstruction to facilitate the success of catheter ablation.

Outcome and safety of intracardiac echocardiography guided left atrial appendage closure within zero-fluoroscopy atrial fibrillation ablation procedures.

Simultaneous atrial fibrillation (AF) catheter ablation and left atrial appendage closure (LAAC) are sometimes recommended for both rhythm control and stroke prevention. However, the advantages of intracardiac echocardiography (ICE) guidance for this combined procedure have been scarcely reported. We aim to evaluate the clinical outcomes and safety of ICE-guided LAAC within a zero-fluoroscopy catheter ablation procedure. From April 2019 to April 2020, 56 patients with symptomatic AF underwent concomitant catheter ablation and LAAC. ICE with a multi-angled imaging protocol mimicking the TEE echo windows was used to guide LAAC. Successful radiofrequency catheter ablation and LAAC were achieved in all patients. Procedure-related adverse event rate was 3.6%. During the 12-month follow-up, 75.0% of patients became free of arrhythmia recurrences and oral anticoagulants were discontinued in 96.4% of patients. No ischemic stroke occurred despite two cases of device-related thrombosis versus an expected stroke rate of 4.8% based on the CHA2 DS2 -VASc score. The overall major bleeding events rate was 1.8%, which represented a relative reduction of 68% versus an expected bleeding rate of 5.7% based on the HAS-BLED score of the patient cohort. The incidence of iatrogenic atrial septal defect secondary to single transseptal access dropped from 57.9% at 2 months to 4.2% at 12 months TEE follow-up. The combination of catheter ablation and LAAC under ICE guidance was safe and effective in AF patients with high stroke risk. ICE with our novel protocol was technically feasible for comprehensive and systematic assessment of device implantation.

Similarity Score for the Identification of Active Sites in Patients With Atrial Fibrillation.

BackgroundAtrial fibrillation (AF) is the most common cardiac arrhythmia and precursor to other cardiac diseases. Catheter ablation is associated with limited success rates in patients with persistent AF. Currently, existing mapping systems fail to identify critical target sites for ablation. Recently, we proposed and validated several individual techniques, such as dominant frequency (DF), multiscale frequency (MSF), kurtosis (Kt), and multiscale entropy (MSE), to identify active sites of arrhythmias using simulated intracardiac electrograms (iEGMs). However, the individual performances of these techniques to identify arrhythmogenic substrates are not reliable.ObjectiveThis study aimed to develop a similarity score using various iEGM analysis techniques to more accurately identify the spatial location of active sites of arrhythmia in patients with AF.MethodsClinical bipolar iEGMs were obtained from patients with AF who underwent either successful (m = 4) or unsuccessful (m = 4) catheter ablation. A similarity score (0–3) was developed via the earth mover’s distance (EMD) approach based on a combination of DF, MSF, MSE, and Kt techniques.ResultsIndividual techniques successfully discriminated between successful and unsuccessful AF ablation patients but were not reliable in identifying active spatial sites of AF. However, the proposed similarity score was able to pinpoint the spatial sites with high values (active AF sites) that were observed only in patients with unsuccessful AF termination, suggesting that these active sites were missed during the ablation procedure.ConclusionArrhythmogenic substrates with abnormal electrical activity are identified in patients with unsuccessful AF termination after catheter ablation, suggesting clinical efficacy of similarity score.

Alternating morphology ventricular tachycardia associated with stable coronary artery disease: A case report

Bidirectional ventricular tachycardia (BVT) is part of the spectrum of polymorphic ventricular tachycardia (VT). This is a case report of a 59-year-old male with stable coronary artery disease and baseline normal left ventricular ejection fraction (LVEF) who was followed for high burden symptomatic monomorphic premature ventricular complexes (PVC). He was admitted for syncope. The ECG showed recurrent non-sustained alternating morphology and double cycle length VT runs associated with deterioration in LVEF but without coronary artery disease progression. The patient had a successful catheter ablation of two distinct left ventricular PVC focus. This is a rare ECG pattern of alternating morphology VT similar to a bidirectional VT.

Ventricular versus atrial side ablation for treatment of atrioventricular accessory pathways: a randomized controlled clinical trial.

The earliest atrial (A)/ventricular (V) activation potentials, or fused A/V potentials, are commonly used as ablation targets for atrioventricular (AV) accessory pathways (APs). However, these targets can be achieved in a relatively wide area of the heart around AV rings at both atrial and ventricular sides. The aim of this study is to analyze the height of intracardiac A and V waves and their correlation to find the most appropriate side for successful delivery of radiofrequency energy, atrial or ventricular edge. Ninety patients diagnosed with orthodromic AV re-entrant tachycardia (AVRT) or Wolff-Parkinson-White syndrome were enrolled. Local atrial/ventricular (A/V) amplitude potentials with the earliest activation or fused AV potentials were measured. Patients were randomly assigned into two groups with a 2:1 ratio. In group 1, ablation was done at the site where A was greater than V. In group 2, V was greater than A. Primary endpoint was success at first attempt, achieving antegrade AP conduction block, AV block during right ventricle pacing, or AVRT termination with no AP conduction. Fifty-one patients (56.7%) were male. Thirty patients had an ablation at an atrial site (A > V) and 60 at a ventricular site (V > A). Ablation was more successful at the ventricular site (87% vs 100%, P = 0.011). All 30 patients in the atrial arm and 71% of the ventricular group underwent ablation via the antegrade method. Success of catheter ablation of APs is higher where V > A (ventricular site of AP), indicating the priority of the ventricular edge of the mitral ring for a better outcome.

Acute efficacy of contiguous versus temporally discontiguous point-by-point radiofrequency pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a randomized study.

Durable pulmonary vein (PV) isolation (PVI) determines the clinical success of catheter ablation for atrial fibrillation. In this randomized study, we investigated whether the temporally discontiguous deployment of ablation lesions adversely affected the acute efficacy of PVI. Thirty-six consecutive patients with drug-refractory paroxysmal atrial fibrillation (aged 59 ± 11, 58% males) were randomized 1:1 to either discontiguous (D-PVI) or contiguous (C-PVI) encircling radiofrequency (RF) lesions around ipsilateral PVs. A contact force-sensing catheter was used targeting a final interlesion distance < 6mm and the ablation index of 400-450 (anterior wall) and 300-350 (posterior wall). The study endpoint was defined as failure of first-pass PVI or acute PV reconnection during a waiting time (> 30min) followed by adenosine challenge. The total RF time, number of RF lesions, and mean interlesion distance were comparable in both groups. Total endpoint rates were 1/36 (3%) in the D-PVI vs 4/36 (11%) in the C-PVI groups; P = 0.34 for superiority, P = 0.008 for non-inferiority. Adenosine-induced reconnection of right PVs was the only endpoint in the D-PVI group. In the C-PVI group, first-pass PVI failed in 2 right PVs and spontaneous reconnection occurred in 2 other circles (left and right PVs). Temporally discontiguous deployment of RF lesions is not associated with lower procedural PVI efficacy when strict criteria for interlesion distance and ablation index are applied. The development of local edema around each ablation site does not prevent effective RF lesion formation at adjacent positions. clinicaltrials.gov (NCT03332862).

Benefits and Risks Associated with Long-term Oral Anticoagulation after Successful Atrial Fibrillation Catheter Ablation: Systematic Review and Meta-analysis.

Oral anticoagulation (OAC) prevents thromboembolism yet greatly increases the risk of bleeding, inciting concern among clinicians. Current guidelines lack sufficient evidence supporting long-term OAC following successful atrial fibrillation catheter ablation (CA). A literature search was performed in PubMed, Google Scholar, Medline, and Scopus to seek out studies that compare continued and discontinued anticoagulation in post-ablation Atrial fibrillation (AF) patients. Funnel plots and Egger’s test examined potential bias. Via the random-effects model, summary odds ratios (OR) with 95% confidence intervals (CI) were calculated using RevMan (5.4) and STATA (17.0). Twenty studies, including 22 429 patients (13 505 off-OAC) were analyzed. Stratified CHA2DS2-VASc score ≥2 examining thromboembolic events (TE) favored OAC continuation (OR 1.86; 95% CI: 1.02-3.40; P = .04). Sensitivity analysis demonstrated this association was attenuated. The on-OAC arm had greater incidence of major bleeding (MB) (OR 0.16; 95% CI: 0.08-0.95; P < .00001), particularly intracranial hemorrhage (ICH) and gastrointestinal bleeding (GI); (OR 0.17; 95% CI: 0.08-0.36; P < .00001) and (OR 0.12; 95% CI: 0.04-0.32; P < .0001), respectively. Our findings support sustained anticoagulation in patients with a CHA2DS2-VASc score of ≥2. Due to reduced outcome robustness, physician discretion is still advised.

Structure and function of the ventricular tachycardia isthmus.

Catheter ablation of postinfarction reentrant ventricular tachycardia (VT) has received renewed interest owing to the increased availability of high-resolution electroanatomic mapping systems that can describe the VT circuits in greater detail, and the emergence and need to target noninvasive external beam radioablation. These recent advancements provide optimism for improving the clinical outcome of VT ablation in patients with postinfarction and potentially other scar-related VTs. The combination of analyses gleaned from studies in swine and canine models of postinfarction reentrant VT, and in human studies, suggests the existence of common electroanatomic properties for reentrant VT circuits. Characterizing these properties may be useful for increasing the specificity of substrate mapping techniques and for noninvasive identification to guide ablation. Herein, we describe properties of reentrant VT circuits that may assist in elucidating the mechanisms of onset and maintenance, as well as a means to localize and delineate optimal catheter ablation targets.

Prediction of mitral regurgitation severity one year after successful catheter ablation for lone long-standing atrial fibrillation

Prediction of mitral regurgitation severity one year after successful catheter ablation for lone long-standing atrial fibrillation

V1r + DIIq is a novel and accurate criterion to predict right vs. left paraseptal accessory pathways

PurposeThe correct estimation of accessory pathway (AP) localization from surface ECG is critical before the procedure. Our study aimed to detect the predictive value of the V1r + DIIq criterion for differentiating right- from left-sided paraseptal APs. MethodsWe retrospectively included 58 patients with (Wolff–Parkinson–White) WPW syndrome and paraseptal APs who underwent successful catheter ablation (37 male, 21 female; mean age 34.4 ± 13.6 years). The V1r + DIIq criterion was calculated using the following formula: V1r + DIIq (mV) = initial r wave amplitude in V1 + q wave amplitude in DII. The combined criterion included V1r + DIIq <2.05 mV and/or no initial r wave in V1. ResultsRight-sided paraseptal APs were detected in 36 patients (62.1%), left-sided paraseptal APs were detected in 21 patients (36.2%), and AP from CS was detected in 1 patient (1.7%). The initial r wave amplitude in V1 (mV), q wave amplitude in DII (mV) and V1r + DIIq criterion (mV) were lower in patients with right-sided paraseptal APs (p < 0.001). The percentage of patients with no initial r wave in V1 (36.1% vs. 0%) and those meeting the combined criterion (91.7% vs. 4.5%) were increased in patients with right-sided paraseptal APs. The cutoff value of the V1r + DIIq criterion obtained by ROC curve analysis was 2.05 mV for predicting right-sided paraseptal APs (sensitivity: 86.1%, specificity: 95.5%). The area under the curve (AUC) was 0.943 (95% CI = 0.881–1.000) (p < 0.001). The sensitivity and specificity values were 36.1% and 100%, respectively, for the no initial r wave criterion and 91.7% and 95.5%, respectively, for the combined criterion. ConclusionThe V1r + DIIq criterion and the combined criterion represent novel and simple electrocardiographic criteria for accurately differentiating right- from left-sided paraseptal APs. This simple ECG measurement can improve the accuracy of detection of paraseptal AP localization and could be beneficial for decreasing ablation duration and radiation exposure.

Abstract 11391: Association Between Smoking History and Response to Rhythm Control Therapy in Atrial Fibrillation Patients Across Race-Ethnicity

Introduction: Although smoking is associated with increased risk of developing atrial fibrillation (AF) and stroke, whether it also predicts response to rhythm control therapy across race-ethnicity remains unclear. Hypothesis: We hypothesize that smokers are less likely to respond to rhythm control therapy for AF than non-smokers. Methods: In this cohort study, patients managed with rhythm control strategy at the time of enrollment to the study were prospectively enrolled in an AF multi-center clinical-DNA biorepository. Rhythm control includes antiarrhythmic drugs (AADs) and\or catheter ablation. Successful response was defined as continuation of the same AAD for at least 6 months and/or successful catheter ablation without recurrence of AF for 12 months. Results: Of the 362 enrolled, 132 (36.4%) were European American, 155 (42.8%) were African- American and 75 (20.7%) were Hispanic American. 125 patients were smokers and 237 patients were non-smokers. Baseline clinical characteristics were similar in both groups (Table 1). Compared to nonsmokers, smokers were less likely to respond to rhythm control strategy (odds ratio [OR] 1.36, 95% confidence interval [CI]: 0.88-2.11, P-value: 0.07). Adjusted for the type of rhythm control, smokers were more likely to have a recurrence of AF catheter ablation as compared with nonsmokers ([OR] 1.38, 95% [CI]: 1.031-2.348, P-value: 0.044). However, there was no significant difference between smokers and non-smokers in terms of response to AADs ([OR] 1.25, 95% [CI]: 0.560-2.809, P-value: 0.292). Conclusions: Patients with a smoking history were less likely to respond rhythm control therapy as compared to nonsmokers. After adjusting for the type of rhythm treatment, smokers were more likely to have a recurrence of AF when compared to non-smokers but there was no difference in response to AADs between the two groups.

Abstract 12160: Predicting Atrial Fibrillation Recurrence After Thoracoscopic Ablation by Left Atrium Appendage Emptying Velocity

Introduction: Totally thoracoscopic ablation (TTA) is the latest tool for in patient with persistent or long-standing atrial fibrillation (AF). Left atrium appendage (LAA) emptying velocity is known related with maintenance sinus rhythm after successful cardioversion and catheter ablation. There were no studies about the value of LAA emptying velocity in thoracoscopic ablation since now. Hypothesis: We assessed the hypothesis that LAA emptying velocity could predict AF recurrence also in patient who underwent TTA. Methods: Between February 2012 and March 2015, 150 patients underwent TTA in a tertiary center in South Korea. The primary outcome was AF recurrence detection in either 12-lead electrocardiogram or holter during 3 years after TTA, excluding initial 3 months of blanking period. After baseline characteristics comparison between no AF recurrence group and AF recurrence group, main contributing factor for AF recurrence was analyzed with multivariable cox regression. Additionally, time-dependent ROC (receiver operating characteristic) analysis was done to estimate predictive power of LAA emptying velocity for AF recurrence. Results: Proportion of paroxysmal AF and LAA emptying velocity were higher in no AF recurrence group. LA volume size was larger in AF recurrence group. Except these values, other clinical characteristics like age, sex, underlying disease, CHA 2 DS 2 -VASc score, history of RFCA, use of antiarrhythmic drug or surgical method were not significantly different. In multivariable cox regression, female sex (HR 2.474, 95% CI [1.036-5.905], p value=0.041) and LAA emptying velocity (HR 0.941, 95% CI [0.915-0.967], p value&lt;0.001) were meaningful contributing factor for AF recurrence. Also, LAA emptying velocity showed modest degree predictive performances for predicting AF recurrence (AUC 0.754, 95% CI [0.675 - 0.834])(figure 1). Conclusions: In conclusion, LAA emptying velocity could predict AF recurrence after TTA.

Abstract 11519: CHA 2 DS 2 VASc Score as a Predictor of Ablation Success Defined by Continuous Long-Term Monitoring

Introduction: There are few readily available and effective risk stratification tools for successful catheter ablation (CA) of atrial fibrillation (AF). CHA 2 DS 2 VASc score is a marker for vascular disease and has been shown to be mildly predictive of CA success, although prior studies have used short-term external monitors to define success. Hypothesis: Lower CHA 2 DS 2 VASc score correlates with CA success as measured by continuous monitoring via cardiac implantable electronic devices (CIED). Methods: Using the Optum® de-identified Electronic Health Record dataset (01/2007 to 06/2019) linked with the Medtronic CareLink device database, we identified patients who underwent a 1 st CA procedure for AF following CIED implantation. CA success was defined as absence of ≥1 hour of AF on any day following a 3-month blanking period. A proportional hazard model was used to estimate hazard ratios (HR) between CHA 2 DS 2 VASc subgroups (0-2, 3-4, ≥5). Results: A total of 665 patients (age 66.9±9.1 years, 73.4% male, CHA 2 DS 2 VASc 3.5±1.8, 37.3% paroxysmal AF, 62.7% persistent AF) were analyzed and included 36.2% insertable cardiac monitor, 28.0% PPM, 21.4% ICD, 13.2% CRT-D, and 1.2% CRT-P. CA success at 24 months post blanking period was 39.8% (95% CI 32.4%-48.9%), 36.9% (95% CI 29.7%-45.8%), and 20.9% (95% CI 13.9%-31.4%) for CHA 2 DS 2 VASc subgroups of 0-2, 3-4, and ≥5, respectively. Kaplan-Meier curves demonstrate a difference in survival free from AF between the three CHA 2 DS 2 VASc subgroups (p=0.007, Figure), with CHA 2 DS 2 VASc score being a significant predictor of CA ablation success (c-statistic 0.533). After controlling for AF type, patients with a score ≥5 remained at higher risk for AF recurrence compared to patients with a score of 0-2 (HR 1.28, 95% CI 1.001-1.63). Conclusions: In this real-world dataset of AF patients with continuous monitoring undergoing CA, CHA 2 DS 2 VASc score is a modest predictor of CA success.

Unusual right bundle branch origin ventricular arrhythmias: Electroanatomical insights for successful catheter ablation

Unusual right bundle branch origin ventricular arrhythmias: Electroanatomical insights for successful catheter ablation

Abstract 1122‐000070: Multiple Watershed Strokes Following Catheter Ablation Procedure

Introduction : Cerebral watershed strokes involve the junction of two non‐anastomosing arterial systems, which are hemodynamic zones at risk. Strokes occur in 3% to 9% of patients after cardiac procedures. The mechanism underlying post‐cardiac surgery watershed stroke involves a combination of hypoperfusion and embolization, but the role of hypoperfusion has not been well elucidated. Watershed strokes in the general population are usually secondary to global hypoperfusion, such as during cardiac arrest, but may also be attributable to stenosis of the carotid artery or other major vessel, leading to local hypoperfusion. Atrial fibrillation confers a threefold to fivefold increase in the risk of stroke, causing 15–20% of all thromboembolic events in the United States. Catheter ablation of atrial fibrillation is the treatment of choice, and currently one of the most commonly performed electrophysiology procedures in the United States. Successful catheter ablation in patients with atrial fibrillation is associated with a decrease in systolic blood pressure. One study showed that in patients with hemodynamically significant stenosis, the average decrease in mean blood pressure during TIA attack was 26.4. mm Hg. In addition, carotid artery stenosis is frequently associated with stenosis of the vertebral arteries, carotid siphon, and cerebral arteries. In these patients, cerebral blood flow is directly dependent on perfusion pressure, due to the loss of normal autoregulatory capacity in the cerebral circulation. Methods : Single Case Study Results : 84‐year‐old male patient with a past medical history of hypertension, gastrointestinal hemorrhage, coronary artery disease status post coronary artery bypass graft, prostate cancer, and atrial flutter on Apixaban status post recent catheter ablation performed five days prior to presentation at the hospital. Patient presented to the emergency room with complaints of spotty vision. The remainder of the neurologic exam was unremarkable. Patient’s vision changes started after the cardiac ablation procedure and progressively worsened. At the time of assessment, NIH score was 1 due to left eye hemianopsia. CT scan of the head without contrast was done and was negative for hemorrhage. CTA of the neck showed 60% stenosis of the left carotid artery. MRI of the brain was done and showed infarct zones between the right anterior cerebral artery and right middle cerebral artery, the right middle cerebral artery and right posterior cerebral artery, the left anterior cerebral artery and left middle cerebral artery, and in the area supplied by the right posterior cerebral artery. Interestingly, based on the radiologic features, all of these strokes happened at approximately the same time. Conclusions : This case demonstrates that even in asymptomatic patients with hemodynamically insignificant carotid stenosis, hypotensive episodes can elicit hemodynamically significant changes that may result in ischemic stroke. Current guidelines don’t include radiologic assessment of the carotid arteries before catheter ablation procedure in patients with known atherosclerotic disease. Based on our findings, in patients with known atherosclerotic disease, we recommend radiologic assessment of the carotid arteries prior to catheter ablation. Patient who undergo catheter ablation usually have an echocardiogram done prior to the procedure.

Left atrial appendage velocity as an instrument of predicting atrial fibrillation recurrence after successful catheter ablation – a useful tool?

Abstract Introduction Catheter ablation for the treatment of Atrial Fibrillation (AF) is a modality of treatment in growing expansion. However the sustained long term response in preventing AF recurrence is poor for most patients, namely in those with a dilated left atrium. Purpose Our aim was to assess the utility of an echocardiographic parameter for left atrium function, the left atrial appendage velocity (LAAV), in predicting recurrences after catheter ablation. Methods We performed a 9 year retrospective analysis of all patients who underwent a successful catheter ablation for the treatment of atrial fibrillation and had a valid pre-procedural transesophagic echocardiogram in a single expert centre. Medical records were analysed for demographic, procedural data and outcomes. Results Seventy-three (73) patients fulfilled all inclusion criteria and were analysed. The mean age was 62±11 with a male preponderance (58,7%). The majority of patients (82,7%) had preserved left ventricle ejection fraction. Only 46% of patient had a volumetric assessment of the left atrium dimensions prior to ablation, with slight, moderate and severe dilation of the left atrium in 20%; 8,6% and 28,6% of patients. Of the patients subjected to an AF ablation the average LAAV was 50,6±19 cm/s, with 78% of patients with normal atrial appendage velocities. Patients with low LAAV (&amp;lt;40cm/s) had a higher proportion of AF recurrences at 3 and 6 months (58,3 vs 12,8% and 89% vs 21,7%; p&amp;lt;0,05 for all) with a linear correlation between the presence of recurrences and LAAV (LAAV of 39,1 vs 57,5 cm/s; p&amp;lt;0,05 OR 0,91 (CI 95% = 0,85–0,97); r2=0,34 at 3 months and LAAV of 43,5 vs 59 cm/s; p=0,01; OR 0,94 (CI 95% = 0,89–0,99); r2=0,24 at 6 months respectively). There was a trend towards association with recurrences at 1 year although it did not reach statistical significance. There was no significant difference in the use of antiarritmic drugs, either prior or post ablation, in both groups. It was not possible to assess the additive predictive value to the left atrium dimensions due to the low percentage of volumetric assessment of left atrium prior to AF ablation. Conclusions Patients with low left atrial appendage velocities had a lower long term success rate of catheter ablation, with higher rates of recurrence at 3 and 6 months and a trend towards higher recurrences at 1 year, with linear correlation which hypothesises the use of the left atrial appendage velocity as novel predictive parameter for an integrative model. Funding Acknowledgement Type of funding sources: None.

Outcome and clinical profile of patients with newly detected atrial fibrillation and cardioembolic stroke

Abstract Background Atrial fibrillation (AF) is a global health care problem with evidence suggesting an increasing prevalence and incidence worldwide. Undiagnosed AF represents the most common cause of thromboembolic events. The aim of the study was to analyze the clinical profile and outcome in patients with cardioembolic stroke and newly detected AF. Methods We enrolled 139 consecutive patients with atrial fibrillation and confirmed diagnosis of ischemic stroke (mean age 72.25±6.33 years, 59 male). Follow-up period was 1 year since the episode of acute stroke. Results All patients with verified cardioembolic stroke were first diagnosed with AF on admission. Patients with AF were characterized by polymorbidity (hypertension was diagnosed in 96 patients, a concomitant chronic renal failure was observed in 60 cases while a complicated course of coronary heart disease – in 35 patients, 22 patients were diagnosed with diabetes mellitus, while 9 people had a long smoking history). Mean value of CHA2DS2-VASc score was 4.51±1.2 and after acute stroke patients were recommended permanent anticoaugulation (12% – warfarin, 45% – rivaroxaban, 24% – apixaban and 19% – dabigatran). At the end of the year of follow-up patients were taking oral anticoagulants only in 16.2% of cases. In the same time only 9.9% of patients had a history of mild or moderate nasal or gingival bleeding (8.2%) while severe hemorrages were not reported. On multivariable analysis, lack of antithrombotic treatment guideline adherence was associated with increased risk of recurrent stroke (hazard ratio, 4.45; 95% confidence interval, 1.25–6.87; P=0.012 for undertreatment). For 3 (2.2%) patients the recurrent sroke was fatal and 2 (1.4%) patients had lethal outcome due to heart failure deterioration after 6 months of follow up. During one year follow up 27 (19.4%) patients had spontaneous AF conversion into sinus rhythm and 19 (13.7%) patients underwent successful catheter ablation. The adjusted risk of reccurent stroke for those in chronic AF was higher than in sinus rhythm (hazard ratio, 1.70; 95% CI, 1.37–2.12). Conclusions This study showed that patients with newly dignosed AF and cardioembolic stroke are characterized with polymorbidity and high thromboembolic risk but after sinus rhythm restoration the adjusted risk of reccurent stroke is much lower. The results demonstrate a low quality care of patients with AF and cardioembolic stroke at the outpatient stage. Appropriate medication compliance is crucial for positive outcomes as well as effectivesecondary stroke prevention in AF patients. Funding Acknowledgement Type of funding sources: None.