One-stop strategy for treatment of atrial fibrillation: feasibility and safety of combining catheter ablation and left atrial appendage closure in a single procedure / 中华医学杂志(英文版)

BACKGROUND@#Catheter ablation is effective in restoring sinus rhythm and left atrial appendage closure (LAAC) is increasingly used for stroke prevention in patients with atrial fibrillation (AF). We aimed to observe the feasibility and safety of performing AF ablation and LAAC in a single (one-stop) procedure.@*METHODS@#Consecutive AF patients who underwent the combined procedure of AF ablation and LAAC with WATCHMAN device between March 2017 and September 2018 were prospectively enrolled. Baseline and intra-procedural parameters were evaluated. Three-month and subsequent 1-year follow-up were performed in all and earlier-enrolled subjects, respectively.@*RESULTS@#A total of 178 AF patients (94 males, 68.9 ± 8.1 years) underwent the one-stop procedure with CHA2DS2-VASc score 3.3 ± 1.5 and HAS-BLED score 1.6 ± 1.0, respectively. Pulmonary vein isolation was achieved in all patients while additional linear ablation was applied if the operator deemed necessary, yielding immediate ablation success rate of 98.9% (176/178). In the subsequent LAAC, satisfactory seal (residual leak <5 mm) was achieved in all patients. One stroke and four cardiac perforations occurred peri-operatively. At 3-month follow-up, sinus rhythm and satisfactory seal were maintained in 153/178 (86.0%) and 178/178 (100%) patients, respectively. One stroke and one delayed cardiac tamponade occurred, while no device-related thrombus or device migration was observed. During the 1-year follow-up for the earlier enrolled subjects, 52/72 (72.2%) of the patients maintained sinus rhythm. There was no stroke or systemic embolism observed.@*CONCLUSION@#Combining catheter ablation and LAAC in a single procedure can be successfully and safely performed in non-valvular AF patients of Chinese population.

Feasibility and perioperative safety of the combined procedure of catheter ablation and watchman left atrial appendage closure / 中华心血管病杂志

Objective: We aimed to explore the feasibility and perioperative safety of performing catheter ablation and left atrial appendage closure (LAAC) in a single (one-stop) session in patients with atrial fibrillation (AF). Methods: This study is an observational study. Consecutive AF patients who underwent the combined procedure of catheter ablation and LAAC with Watchman device of Xinhua Hospital in Shanghai between March 2017 and May 2019 were prospectively enrolled. Baseline, intra-and peri-procedural parameters were evaluated. Results: A total of 358 AF patients (189 males, (69.0±8.0) years) underwent the one-stop procedure. The CHA2DS2-VASc score was 3.2±1.5 and HAS-BLED score was 2.4±1.1, respectively in this patient cohort. Pulmonary vein isolation was achieved in all patients, while additional linear ablation was applied in 180 (50.3%) patients, yielding immediate success rate of 99.7%. Successful Watchman implantation was achieved in all patients. The perioperative serious adverse event occurred in 14 cases (3.9%). including 6 pericardial effusions (1.7%), 1 stroke (0.3%) and 5 vascular complications (1.4%), yielding procedure-related complication rate of 3.4%. In addition, 2 (0.6%) new-onset heart failures occurred postoperatively. There was no major bleeding or death during the perioperative period. Conclusions: Combined catheter ablation and LAAC can be successfully and safely performed in AF patients with high stroke risk. Follow-up data are needed to evaluate the outcome of this one-stop procedure.

A low-pass filter of 300 Hz improved the detection of pacemaker spike on remote and bedside electrocardiogram / 中华医学杂志(英文版)

BACKGROUND@#The current upper-frequency cutoff of 150 Hz sometimes causes loss of pacemaker spike and misdiagnosis. We hypothesized that low-pass filter (LPF) other than 150 Hz could improve the detection of pacemaker spike. This study aimed to examine the effect of different LPF on pacemaker spike detection in remote and bedside electrocardiogram (ECG).@*METHODS@#Patients with permanent pacemaker implantation were included during routine follow-up. Standard 12-lead ECGs at 6 different upper-frequency cutoff (40, 100, 150, 200, 300, and 400 Hz) were collected. All ECGs were then transmitted to the remote clinic center. Ventricular and atrial pacing were analyzed by 2 independent medical practitioners.@*RESULTS@#A total of 88 patients' ECGs were analyzed (mean age 73.8 ± 10.2 years and 85 with dual-chamber pacemakers). About 75.3% (64/85) of patients were diagnosed as atrial pacing by pacemaker programming. Among 6 different upper-frequency cutoff, the 300 Hz turned out to perform best in detecting atrial-paced spike (area under the curve [AUC] = 0.73, 95% confidence interval [CI]: 0.61-0.84 vs. 0.56, 95% CI: 0.61-0.84 at 150 Hz; P = 0.002) on bedside ECGs. Using programming as the golden standard, the 300 Hz LPF has a sensitivity of 59.4%, specificity of 85.7%, positive predictive value of 92.7% and negative predictive value of 40.9% on bedside ECGs. As for the ventricular pacing, the 300 Hz LPF also had a higher accuracy (AUC = 0.93; 95% CI = 0.84-1.00) than that at 150 Hz (AUC = 0.86; 95% CI: 0.77-0.94; P < 0.001) in detecting ventricular-paced spike on bedside ECGs. The results of remote ECGs were similar with bedside ECGs.@*CONCLUSIONS@#A filter of 300 Hz cutoff may be recommended for ECG spike detection. With the recommended parameter, remote ECG can perform as well as bedside ECG.

Value of Combining Left Atrial Diameter and Amino-terminal Pro-brain Natriuretic Peptide to the CHA2DS2-VASc Score for Predicting Stroke and Death in Patients with Sick Sinus Syndrome after Pacemaker Implantation / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The CHA2DS2-VASc score is used clinically for stroke risk stratification in patients with atrial fibrillation (AF). We sought to investigate whether the CHA2DS2-VASc score predicts stroke and death in Chinese patients with sick sinus syndrome (SSS) after pacemaker implantation and to evaluate whether the predictive power of the CHA2DS2-VASc score could be improved by combining it with left atrial diameter (LAD) and amino-terminal pro-brain natriuretic peptide (NT-proBNP).</p><p><b>METHODS</b>A total of 481 consecutive patients with SSS who underwent pacemaker implantation from January 2004 to December 2014 in our department were included. The CHA2DS2-VASc scores were retrospectively calculated according to the hospital medical records before pacemaker implantation. The outcome data (stroke and death) were collected by pacemaker follow-up visits and telephonic follow-up until December 31, 2015.</p><p><b>RESULTS</b>During 2151 person-years of follow-up, 46 patients (9.6%) suffered stroke and 52 (10.8%) died. The CHA2DS2-VASc score showed a significant association with the development of stroke (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.20-1.75, P< 0.001) and death (HR 1.45, 95% CI 1.22-1.71, P< 0.001). The combination of increased LAD and the CHA2DS2-VASc score improved the predictive power for stroke (C-stat 0.69, 95% CI 0.61-0.77 vs. C-stat 0.66, 95% CI 0.57-0.74, P= 0.013), and the combination of increased NT-proBNP and the CHA2DS2-VASc score improved the predictive power for death (C-stat 0.70, 95% CI 0.64-0.77 vs. C-stat 0.67, 95% CI 0.60--0.75, P= 0.023).</p><p><b>CONCLUSIONS</b>CHA2DS2-VASc score is valuable for predicting stroke and death risk in patients with SSS after pacemaker implantation. The addition of LAD and NT-proBNP to the CHA2DS2-VASc score improved its predictive power for stroke and death, respectively, in this patient cohort. Future prospective studies are warranted to validate the benefit of adding LAD and NT-proBNP to the CHA2DS2-VASc score for predicting stroke and death risk in non-AF populations.</p>

Adenosine sensitivity is associated with ablation success rate and recurrence rate with nonirrigated catheters in patients with ventricular premature contractions/tachycardia from the ventricular outflow tract / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>A high ablation success rate for ventricular arrhythmia (VA) from outflow tract has been achieved, but some of them cannot be eliminated from endocardium. We investigated the association between adenosine sensitivity and ablation success/recurrence rates with a nonirrigated or an irrigated catheter.</p><p><b>METHODS</b>According to adenosine test, all patients were divided into a sensitive group (S group) or an insensitive group (I group). The patients of each group were randomized into a nonirrigated catheter (NA) subgroup or an irrigated catheter (IA) subgroup with a 2:1 ratio.</p><p><b>RESULTS</b>In S group of 122 patients (84 in NA subgroup), the ablation success rate was similar between two subgroups (94.7% vs. 90.5%, P > 0.05), but in I group of 94 patients (60 in NA subgroup), it was higher in IA subgroup (94.1%) than that in NA subgroup (73.3%, P < 0.05). The success rate using nonirrigated catheter was significantly higher in S group (90.5%) than that in I group (73.3%, P < 0.01), and the recurrence rate was lower in S group than that in I group (1.3%, vs. 13.6%, P < 0.05). On the contrary, the success rate and the recurrence rate using irrigated catheter were similar between S group and I group (94.7%, 94.1%, P > 0.05, vs. 2.8%, 6.3%, P > 0.05).</p><p><b>CONCLUSIONS</b>Adenosine insensitivity is associated with a lower success rate and a higher recurrence rate for VA patients undergoing nonirrigated catheter ablation. Thus, irrigated catheters should be the first choice for VA ablation in adenosine insensitive patients.</p>

Pulmonary vein antrum isolation of pre-excited atrial fibrillation / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Pulmonary vein antrum isolation (PVAI) of pre-excited atrial fibrillation (AF) is controversial. This study aimed to observe the therapeutic effects of PVAI on pre-excited AF.</p><p><b>METHODS</b>Twenty-nine patients with pre-excited AF were prospectively divided into a PVAI group (group I, 19 cases) and a control group (group II, 10 cases). To each case in group I, PVAI was performed, and then electroanatomical mapping of accessory pathways (AP) and ablation were constructed on a three-dimensional (3D) map of the valve annulus. Only AP ablation was performed in each case of group II.</p><p><b>RESULTS</b>Of the 29 cases, three were found to have dual APs, two had intermittent APs, and the remaining 24 had single APs. All APs were successfully ablated after the procedure. There were no significant statistical differences in the AP procedure duration ((77.4 ± 21.3) minutes vs. (85.3 ± 13.1) minutes), the AP ablation time ((204 ± 34) seconds vs. (223 ± 62) seconds) and the AP X-ray exposure time ((18.6 ± 4.4) minutes vs. (19.1 ± 4.5) minutes) respectively between groups I and II. As compared with the control group (5 of 10 cases, 50%), the PVAI group had a significantly lower AF recurrence rate (2 of 19 cases, 11%; P < 0.05) during follow-up of (20.5 ± 10.0) months. All seven patients who recurred were successfully abolished by a second ablation.</p><p><b>CONCLUSIONS</b>In patients with pre-excited AF, PVAI is an effective therapeutic approach with a low AF recurrence rate. 3D electroanatomical maps of AP contributed to the high success rate of ablation without significantly prolonging of operational duration and X-ray exposure time.</p>

Absence of gender disparity in short-term clinical outcomes in patients with acute ST-segment elevation myocardial infarction undergoing sirolimus-eluting stent based primary coronary intervention: a report from Shanghai Acute Coronary Event (SACE) Registry / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Randomized, controlled trials have demonstrated the superiority of sirolimus-eluting stent (SES) implantation during primary percutaneous coronary intervention (PCI), as opposed to bare-metal stents, in patients with ST-elevation myocardial infarction (STEMI). This study aimed to test the hypothesis that clinical benefits of SES treatment were independent of gender in this setting.</p><p><b>METHODS</b>A total of 2042 patients with STEMI undergoing SES-based primary PCI were prospectively enrolled into Shanghai Acute Coronary Event (SACE) registry (1574 men and 468 women). Baseline demographics, angiographic and PCI features, and in-hospital and 30-day major adverse cardiac events (MACE) were analyzed as a function of gender.</p><p><b>RESULTS</b>Compared with men, women were older and more frequently had hypertension, diabetes, and hypercholesterolemia. Use of platelet glycoprotein IIb/IIIa receptor inhibitor (GPI, 65.5% vs. 62.2%, P = 0.10) and procedural success rate (95.0% vs. 94.2%, P = 0.52) were similar in both genders. In-hospital death and MACE occurred in 3.8% and 7.6%, and 4.5% and 8.1% in the male and female patients, respectively (all P > 0.05). At 30-day follow-up, survival (94.3% vs. 93.8%, P = 0.66) and MACE-free survival (90.2% vs. 89.3%, P = 0.52) did not significantly differ between men and women. After adjustment for differences in patient demographics, angiographic and procedural features, there were no significant difference in either in-hospital (OR = 0.77, 95%CI of 0.48 to 1.22, P = 0.30) or 30-day mortality (OR = 1.28, 95%CI of 0.73 to 2.23, P = 0.38) between women and men.</p><p><b>CONCLUSION</b>Despite more advanced age and clustering of risk factors in women, female patients with STEMI treated by SES-based primary PCI had similar in-hospital and short-term clinical outcomes as their male counterparts.</p>

Chronic outcome of patients with nonparoxysmal atrial fibrillation underwent CARTO-guided stepwise ablation / 中华心血管病杂志

<p><b>OBJECTIVE</b>To investigate the efficacy of CARTO-guided stepwise ablation approaches for treatment of patients with nonparoxysmal atrial fibrillation(AF).</p><p><b>METHODS</b>Stepwise ablation approaches were performed in 40 patients with nonparoxysmal atrial fibrillation. Pulmonary vein atrium isolation (PVAI), linear ablation in atria, complex fractionated atrial electrograms (CFAEs) ablation and cardioversion were applied sequentially till sinus rhythm (SR) restoration. All patients were followed up 6 to 18 months.</p><p><b>RESULTS</b>SR was restored in 11 patients after PVAI, in 11 patients after linear ablation and in 6 patients after CFEAs ablation. SR was restored in the remaining 13 patients post cardioversion. During follow-up, 3 atrial fibrillation, 3 atrial tachycardia and 5 atrial flutter were evidenced. Seven out of the 11 patients with reoccurred arrhythmia were treated only by PVAI.</p><p><b>CONCLUSIONS</b>CARTO-guided stepwise ablation approaches are safe and effective in the treatment of patients with nonparoxysmal atrial fibrillation. PVAI approach was associated with lower successful rate and high recurrence rate.</p>

Combined use of extended-release niacin and atorvastatin: safety and effects on lipid modification / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Cholesterol-lowering therapy with statins has been reported to reduce the morbidity and mortality of cardiovascular diseases. This study aimed to investigate the effects of combined application of extended-release niacin and atorvastatin on lipid profile modification and the risks of adverse events in patients with coronary artery disease.</p><p><b>METHODS</b>Consecutive 108 patients with coronary artery disease and serum total cholesterol (TC) > or = 3.5 mmol/L were randomized into two groups: group A using atorvastatin and group B using extended-release niacin (niacin ER) and atorvastatin. Plasma lipid profile, glucose, and adverse events were assessed at the hospitalization, and 6 and 12 months after treatment. In addition, clinical cardiovascular events were evaluated after 12 months of treatment.</p><p><b>RESULTS</b>The levels of TC, low density lipoprotein cholesterol (LDL-C) were significantly decreased (P < 0.05) in groups A and B, but the levels of high density lipoprotein cholesterol (HDL-C) and ApoA increased by 29.36% and 40.81% respectively after 12 months of treatment in group B (P < 0.01). The medications were generally well tolerated in the two groups. No significant difference of adverse events was found between the two groups (group A: 3.2% vs group B 5.1%, P > 0.05).</p><p><b>CONCLUSIONS</b>Combined use of extended-release niacin with atorvastatin was superior to atorvastatin monotherapy alone in lipid profile regulation. Combination therapy with niacin ER and atorvastatin was well tolerated and safe in patients with coronary artery disease.</p>

Refinement of CARTO-guided substrate modification in patients with ventricular tachycardia after myocardial infarction / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Substrate modification guided by CARTO system has been introduced to facilitate linear ablation of ventricular tachycardia (VT) after myocardial infarction (MI). However, there is no commonly accepted standard approach available for drawing these ablation lines. Therefore, the aim of the present study was to practically refine this time consuming procedure.</p><p><b>METHODS</b>Substrate modification was performed in 23 consecutive patients with frequent VTs after MI using the CARTO system. The initial target site (ITS) for ablation was identified by pace mapping (PM) during sinus rhythm and/or entrainment pacing (EM) during VT. According to the initial target site, two approaches were used. The initial target site in approach one has a similar QRS morphology as VT and an interval from the stimulus to the onset of QRS complex (S-QRS) of = 50 ms during PM in sinus rhythm or a difference of the post pacing interval and VT cycle length = 30 ms during concealed entrainment pacing of VT; The initial target site in approach two has an similar QRS morphology as VT and an S-QRS of < 50 ms during PM in sinus rhythm.</p><p><b>RESULTS</b>Overall, 50 lines were performed with a length of (35 +/- 11) mm. Procedure time averaged (232 +/- 56) minutes, fluoroscopy time (10 +/- 8) minutes. Sixteen patients were initially involved into approach one. After completion of 3 +/- 1 ablation lines, no further VT was inducible in 13 patients. The remaining 3 patients were switched to use the alternative approach. However, in none of them the alternative approaches were successful. Approach two was initially used in 7 patients. After completion of 3 +/- 1 ablation lines, no further VT was inducible in only 2 patients. The remaining 5 patients were switched to approach one, which resulted in noninducibility of VT in 4 of them. The initial successful rate was significantly higher in the group of approach one compared to that in the group of approach two (13/16 patients vs 2/7 patients, P = 0.026).</p><p><b>CONCLUSIONS</b>The approach for substrate modification of VT after MI can be optimized by identifying the appropriate initial target site with specific characteristics within the zone of slow conduction. The refined approach may facilitate linear ablation of VT, and further reduce the procedure and fluoroscopy time.</p>

Stepwise approach to substrate modification of ventricular tachycardia after myocardial infarction / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Recently, substrate mapping (SM) has been described to facilitate catheter ablation of stable and unstable ventricular tachycardia (VT) after myocardial infarction. However, SM is time consuming with potential disadvantages of multiple ablation lines such as impairment of ventricular function or proarrhythmia. The aim of the present study was to delineate a stepwise approach to SM to shorten procedure time and limit the possibility of complications.</p><p><b>METHODS</b>SM was performed in 14 infarct survivors referred for VT ablation using an electroanatomical mapping system (CARTO) to define infarct regions. A new stepwise approach for SM was designed as follows. The initial ablation site was identified by pace- and entrainment mapping in case of stable VT and by pace mapping only in case of unstable VT. Based on the CARTO voltage mapping, linear ablation was done from this site to the center of the scar and perpendicular to the boundary of the scar or to the mitral annulus. Additional lines were performed only when VT remained inducible. A maximum of 3 ablation lines were created during one procedure.</p><p><b>RESULTS</b>A total of 57 VTs (21 stable, 36 unstable) were induced during the procedures. VT was no longer inducible after the first linear ablation in 2 patients, after the second linear ablation in 6 patients and after the third linear ablation in 3 patients. Either VT or ventricular fibrillation was still inducible at the end of the procedure in 3 patients. Procedure time averaged (291 +/- 85) minutes, fluoroscopy time (10 +/- 7) minutes. VT recurred in 3 patients. Following a second procedure in 2 patients, there were no further VT recurrences. Overall, there was a significant reduction in VT episodes 3 months after [median: 0, interquartile ranges (IQR): 0 - 1] compared with 3 months before ablation (median: 25, IQR: 16 - 105, P < 0.01).</p><p><b>CONCLUSIONS</b>This stepwise approach to SM is effective in facilitating ablation of stable and unstable VT. It reduces procedure and fluoroscopy time, and may help to improve the risk-benefit ratio of VT ablation.</p>

Radiofrequency catheter ablation in patients with symptomatic atrial flutter/tachycardia after orthotopic heart transplantation / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Atrial tachycardia or flutter is common in patients after orthotopic heart transplantation. Radiofrequency catheter ablation to treat this arrhythmia has not been well defined in this setting. This study was conducted to assess the incidence of various symptomatic atrial arrhythmias and the efficacy and safety of radiofrequency catheter ablation in these patients.</p><p><b>METHODS</b>Electrophysiological study and catheter ablation were performed in patients with symptomatic tachyarrhythmia. One Halo catheter with 20 poles was positioned around the tricuspid annulus of the donor right atrium, or positioned around the surgical anastomosis when it is necessary. Three quadripolar electrode catheters were inserted via the right or left femoral vein and positioned in the recipient atrium, the bundle of His position, the coronary sinus. Programmed atrial stimulation and burst pacing were performed to prove electrical conduction between the recipient and the donor atria and to induce atrial arrhythmias.</p><p><b>RESULTS</b>Out of 55 consecutive heart transplantation patients, 6 males [(58 +/- 12) years] developed symptomatic tachycardias at a mean of (5 +/- 4) years after heart transplantation. Electrical propagation through the suture line between the recipient and the donor atrium was demonstrated during atrial flutter or during recipient atrium and donor atrium pacing in 2 patients. By mapping around the suture line, the earliest fragmented electrogram of donor atrium was assessed. This electrical connection was successfully ablated in the anterior lateral atrium in both patients. There was no electrical propagation through the suture line in the other 4 patients. Two had typical atrial flutter in the donor atrium which was successfully ablated by completing a linear ablation between the tricuspid annulus and the inferior vena cava. Two patients had atrial tachycardia which was ablated in the anterior septal and lateral donor atrium. There were no procedure-related complications. Patients were free of recurrent atrial tachyarrhythmias after a follow-up of (8 +/- 7) months.</p><p><b>CONCLUSIONS</b>Four electrophysiological mechanisms have been found to contribute to the occurrence of symptomatic supraventricular arrhythmias following heart transplantation. Radiofrequency catheter ablation in patients with atrial flutter/tachycardia is feasible and safe after heart transplantation.</p>

Advances in catheter ablation of chronic atrial fibrillation / 上海第二医科大学学报

Catheter ablation of atrial fibrillation is an evolving field,especially for chronic atrial fibrillation.Several approaches have been performed in clinic practice,which include circumferential pulmonary vein ablation/isolation,left atrial linear ablation,CFAE ablation,pulmonary vein denervation or stepwise ablation.However,a standard approach has not been established.The total successful rates vary from 21% to 95%.The investigations in the mechanism of chronic atrial fibrillation and methods of three-dimensional mapping,and the usage of new source and technique of ablation will increase the successful rate,decrease the recurrence rate and procedure time.The long-term result of ablation of chronic atrial fibrillation and its impact on the structure and function of heart need further investigations.