Association of left atrial enlargement and increased left ventricular wall thickness with arrhythmia recurrence after cryoballoon ablation for atrial fibrillation.

BACKGROUND: Left atrial enlargement (LAE) predicts atrial fibrillation (AF) recurrence after cryoballoon-based pulmonary vein isolation (CB). Increased left ventricular wall thickness (LVWT) is pathophysiologically associated with LAE and atrial arrhythmias. AIMS: To assess effect of increased LVWT on long-term outcomes of CB depending on coexistence of LAE. METHODS: LAE was defined using either echocardiography ( > 48 cm³/m²) or multislice computer tomography (MSCT, ≥63 cm³/m²). Increased LVWT was echocardiographic septal/posterior wall thickness > 10 mm in males and > 9 mm in females. All patients achieved 2-year follow-up. RESULTS: Of 250 patients (median [interquartile range, IQR] age of 61 [49.0-67.3] years; 30% female) with AF (40% non-paroxysmal), 66.5% had hypertension, and 27.2% underwent redo procedure. MSCT was done in 76%. During follow-up of 24.5 (IQR, 6.0-31.00) months the clinical success rate was 72%, despite 46% of patients having arrhythmia recurrence. Arrhythmia recurrence risk was increased by LAE and increased LVWT (hazard ratio [HR], 1.801; P = 0.002 and HR, 1.495; P = 0.036; respectively). The highest arrhythmia recurrence (61.9% at 2 years) was among patients with LAE and increased LVWT (33.6% of patients); intermediate (41.8%) among patients with isolated LAE; and lowest among patients with isolated increased LVWT or patients without LAE or increased LVWT (36.8% and 35.2% respectively, P = 0.004). After adjustment for body mass index (BMI), paroxysmal AF, CHA2DS2-VASc score, clinically-significant valvular heart disease, and cardiomyopathy, patients with LAE and concomitant increased LVWT diagnosis had a 1.8-times increased risk of arrhythmia recurrence (HR, 1.784; 95% confidence interval [CI], 1.017-3.130; P = 0.043). CONCLUSION: Joint occurrence of LAE and increased LVWT is associated with the highest rate of arrhythmia recurrence after CB for AF.

Early stage of left atrium remodelling predicts better outcome in long-term follow-up of atrial fibrillation ablation.

BACKGROUND: Radiofrequency catheter ablation (RFCA) has been increasingly used for the treatment of patients with symptomatic atrial fibrillation (AF). AIM: To identify simple pre-procedural success predictors of RFCA in patients with AF. METHODS AND RESULTS: It comprised 294 consecutive patients (mean age 54 ± 11 years, 71% male) with symptomatic AF (28% - paroxysmal with short episodes (< 12 h); 50% - paroxysmal with episodes ≥ 12 h and < 7 days; 11.5% - persistent; 10.5% - long standing persistent), having undergone the first RFCA. Before RFCA, all patients underwent pulmonary vein (PV) anatomy imaging and echocardiographic left atrium diameter (LAD) evaluation. PV periostial or antral isolation guided by electroanatomical mapping was performed with additional lines or complex fractionated electrograms ablation (if required). Outcomes were defined as clinical success (complete or improvement) or failure. After a mean follow-up of 36.9 ± 13 months, clinical success was observed in 90.5% of patients, made up of 47.3% complete success, and 43.2% improvement. Patients with short AF episodes underwent fewer procedures (1.6 vs. 2, p = 0.026) and had the highest clinical (97.6%) and complete (63.9%) success rates. AF episodes < 12 h (p < 0.001), LAD < 4 cm (p = 0.01) and male gender (p = 0.002) independently predicted RFCA long-term clinical success. PV anatomy did not correlate with RFCA outcome. A trend was observed towards a larger number of procedures in patients with atypical PV anatomy (p = 0.059). CONCLUSIONS: AF ablation should be performed in the early stage of AF, before structural remodelling development.

Ventricular fibrillation risk factors in over one thousand patients with accessory pathways.

BACKGROUND: Published data concerning risk factors of VF in WPW patients are inconsistent or contradictory. METHODS AND RESULTS: We included 1007 patient (pts) (mean age 35 years; 45% female) with an accessory pathway (AP) referred for non pharmacological treatment. Group 1 consisted of 56 pts (42M, aged 34 ± 15 yrs) with an AP and documented VF and Group 2-951 pts (513M, aged 35 ± 15 yrs) with an AP and without VF. Univariate predictors of VF were: overt pre-excitation, male gender, multiple AP, large AP. Multivariate predictors were: overt pre-excitation, male gender and MAP. The mean shortest pre-excited RR interval during AF was significantly shorter in Group 1: 205 ± 27 vs. 243 ± 64, P=0.019. VF as an end point of the first arrhythmia episode (AVRT or AF) was observed in 20 pts (15M, 5F). Primary VF (no documented arrhythmia prior to aborted SCD) occurred in 16 pts (13M, 3F). The mean age of primary VF pts was significantly lower than of pts with history of AVRT or AVRT and/or AF (24.5 vs. 36.5 vs. 38 yrs., P<0.005 and P=0.002, respectively). Age at VF occurrence shows a bi-modal distribution with peak occurrences in the 2-nd/3-rd and 5-th decades. CONCLUSION: In patients with an accessory pathway, overt pre-excitation, male gender and multiple AP constitute independent risk factors of VF episodes. Young patients in the 2-nd/3-rd and older patients in the 5-th decade might be at higher risk of VF occurrence.

The clinical course and risk in patients with pseudo-Mahaim fibers.

BACKGROUND: Pseudo-Mahaim (AP-M) fibers are a rare variant of atrioventricular (AV) accessory pathways. Atriofascicular and atrioventricular accessory connections are characterized by slow conduction and decremental properties. Dual physiological AV node pathways, slow and fast, are observed in a large number of patients with AP-M. Therefore, there is substrate for AV nodal reentrant tachycardia (AVNRT) in addition to antidromic AV reentrant tachycardia (AVRT) with left bundle branch block (LBBB)-like morphology. Other arrhythmia such as atrial fibrillation (AF) or atrial flutter (AFL) and ventricular fibrillation (VF) are also observed. We analysed the occurrence of arrhythmias in a group of patients with AP-M treated in our department. METHODS: We evaluated 27 patients (12 women) aged 14-53 years (mean age 25.6 years) with AP-M. The clinical course in these patients, in particular with regard to the occurrence of arrhythmias, was analysed. Patients with dual AV node properties were compared to patients without such findings. RESULTS: We found dual AV node properties in 18 patients (Group 1), while 9 patients had fast pathway only (Group 2). Twenty-six patients presented with AVRT, 2 patients with AVNRT, 3 patients with AF, 1 patient with AT, 2 patients with AFL, and 3 patients with VF. In 2 patients, AP-M were seen in an atypical area. In one patient, the pathway connected the right atrium with the left ventricle (septal region), and in the other patient it connected the left atrium with the left ventricle (left anterior region). CONCLUSIONS: The majority of AP-M was right-sided. Two thirds of patients with AP-M had anatomical substrate for AVNRT (fast/slow pathway AV node). VF or asystole occurred in 10% of patients.

[Glass of water or ablation? - episodes of malignant atrial tachyarrhythmias during swimming in a lake in a woman with overt Wolff-Parkinson-White syndrome and benign palpitations for several decades of life]. / Szklanka wody czy ablacja? - napad zlosliwych arytmii przedsionkowych w czasie plywania w jeziorze u chorej z jawnym zespolem Wolffa-Parkinsona-White'a i z lagodnymi napadami kolatania serca przez kilka dekad zycia.

We present a case of a 41 year old woman with overt Wolff-Parkinson-White syndrome (WPW) and benign palpitations for over four decades of life who suffered from a malignant atrial tachyarrhythmias (typical atrial flutter concomitant with left atrial fibrillation) during swimming in a lake. Loading dose of amiodarone increased frequency of attacks of sustained AVRT. In spite of treatment with amiodarone, effective refractory period of accessory pathway was still short. After ablation of accessory pathway, during five years of follow-up, there was no arrhytmia recureence.

[Arrhythmias originating from coronary sinus with multi-level conduction block as a cause of tachyarrhythmic cardiomyopathy reversed by successful RF ablation]. / Zespól ogniskowych tachyarytmii z zatoki wiencowej przyczyna kardiomiopatii, która ustapila po skutecznej ablacji ogniska.

A patient with a 6-year history of drug-resistant, recurrent arrhythmias (AT/AFL, single SVEBs, pairs and series) developed arrhythmogenic cardiomyopathy. Conduction block between coronary sinus (CS) and atria caused periodical change of tachycardia's rate. Successful RF ablation performed in the middle of CS at a place of spike potentials of a 284 ms CL. During a 6-years follow-up after ablation, ejection fraction increased from 38 to 59% and the quality of life improved significantly.