Long-Term Impact of Right Ventricular Pacing on Left Ventricular Systolic Function in Pacemaker Recipients With Preserved Ejection Fraction: Results From a Large Single-Center Registry.

BACKGROUND: There is limited evidence of long-term impact of right ventricular pacing on left ventricular (LV) systolic function in pacemaker recipients with preserved LV ejection fraction (LVEF). The objective of the study was to evaluate the outcome and echocardiographic course of baseline preserved LVEF in a large cohort of pacemaker recipients with respect to pacing indication and degree of right ventricular pacing. METHODS AND RESULTS: We enrolled 991 patients (73±10 years, 54% male) with baseline normal (>55%) LVEF (n=791) or mildly reduced (41-55%) LVEF (n=200) who had paired echocardiographic data on LV systolic function recorded at implantation and last follow-up. According to pacing indication, patients were divided into atrioventricular block group A (n=500) and sinus node disease group B (n=491). Main outcome measures were all-cause mortality and deterioration of LV function ≥2 LVEF categories at last follow-up. Patients were followed for an average of 44 months. Death from any cause occurred in 166 (17%), and deterioration of LV function ≥2 LVEF categories in 56 (6%) patients. There was no significant difference in outcome between group A and group B either in patients with normal LVEF or in those with mildly reduced LVEF. Mean percentage of right ventricular pacing was not predictive of outcome. CONCLUSIONS: In a large cohort of pacemaker recipients with predominantly normal LVEF, clinically relevant LV dysfunction develops rather infrequently. No significant difference in all-cause mortality and development of severe LV dysfunction is observed between patients with atrioventricular block and sinus node disease. Accordingly, de novo biventricular pacing cannot be recommended for patients with preserved LVEF.

The impact of body mass index on the efficacy and safety of catheter ablation of atrial fibrillation.

BACKGROUND: Obesity is a well established risk factor for atrial fibrillation (AF) development. Our purpose was to determine the impact of body mass index (BMI) on the safety and efficacy of radiofrequency catheter ablation of AF. METHODS: Two hundred and twenty-six consecutive patients with symptomatic, drug-refractory paroxysmal (59.3%) and persistent (40.7%) AF underwent wide circumferential electrical pulmonary vein isolation. Patients were classified according to BMI as normal (<25kg/m(2)); overweight (25 to 29.9kg/m(2)); and obese (≥30kg/m(2)). RESULTS: Patients with high BMI were younger and displayed a higher rate of hypertension, increased left atrial diameter, increased left ventricular end-diastolic and end-systolic diameters, and increased levels of several conventional markers of inflammation and oxidative stress including white blood cell count, fibrinogen, uric acid, alanine aminotransferase, and gamma-glutamyltransferase (p<0.05). After a mean follow-up period of 432.32±306.09days from the index procedure, AF recurrence rate was 34.9% for normal weight, 46.2% for overweight, and 46.2% for obese patients (p: 0.258). Subjects classified above the 50th percentile for BMI displayed a trend toward a higher AF recurrence rate (p: 0.08). In univariate Cox regression survival analysis, BMI was not predictive of AF recurrence. Radiation exposure was significantly higher in overweight and obese patients in relation to normal weight patients (p: 0.003). No significant differences regarding major complications were observed among BMI groups. CONCLUSIONS: In this study population, BMI was not an independent predictor of AF recurrence following left atrial catheter ablation.

Cellular damage, platelet activation, and inflammatory response after pulmonary vein isolation: a randomized study comparing radiofrequency ablation with cryoablation.

BACKGROUND: Experimental data suggest that use of cryoablation in pulmonary vein isolation (PVI) is associated with less cell damage and less thrombus formation compared to radiofrequency (RF) energy. OBJECTIVE: The purpose of this study was to test the hypothesis that cryoablation significantly reduces markers of cell damage, platelet activation, and inflammation in patients undergoing PVI for treatment of atrial fibrillation (AF). METHODS: Sixty patients with symptomatic drug-resistant AF (age 56 ± 9 years, 48 males, 38 with paroxysmal AF) were randomly assigned to undergo PVI using either an open irrigated-tip RF catheter or a cryoballoon. Markers of cell damage (high-sensitive troponin T [hs-TnT], microparticles), platelet activation (platelet reactivity by aggregometry, expression of platelet surface proteins P-selectin and activated glycoprotein [GP] IIb/IIIa), and inflammatory response (high-sensitive C-reactive protein [hs-CRP]) were determined before and up to 48 hours after the procedure. RESULTS: PVI resulted in a significant rise in hs-TnT, microparticles, markers of platelet activation, and hs-CRP over time, with distinct temporal patterns for each parameter. However, after Bonferroni correction for repeated measurements, no significant differences were noted in these parameters between patients treated with cryoablation or RF energy. Procedural time was significantly shorter in patients treated with cryoballoon (177 ± 30 minutes vs 200 ± 46 minutes, P = .03), with no differences in fluoroscopic time, periprocedural complications, or success rate. CONCLUSION: Cryoablation and RF energy result in a comparable rise of markers of cell damage, platelet activation and inflammatory response. The data do not support the concept of an improved safety profile for cryoablation in PVI.

Long-term prognosis of asymptomatic individuals with spontaneous or drug-induced type 1 electrocardiographic phenotype of Brugada syndrome.

BACKGROUND: Risk stratification of asymptomatic individuals with type 1 electrocardiogram (ECG) phenotype of Brugada syndrome (BS) still remains controversial. This study investigated the long-term prognosis of asymptomatic subjects with spontaneous or drug-induced type 1 ECG pattern of BS. METHODS AND RESULTS: Data from 33 apparently healthy individuals (30 males; age, 43.6 ± 13.4 years) with spontaneous (n = 12) or drug-induced (n = 21) type 1 ECG pattern of BS were retrospectively analyzed. Thirteen subjects (39.4%) displayed a positive family history of BS and/or sudden cardiac death. Electrophysiologic study was performed in 16 subjects, and programed right ventricular stimulation induced polymorphic ventricular tachycardia in 9 (56.3%) of them. A cardioverter defibrillator was implanted in 6 cases. During a mean follow-up period of 5.3 ± 2.8 years, all subjects remained asymptomatic. None of them had syncope or cardioverter defibrillator discharges due to ventricular arrhythmias. CONCLUSIONS: Asymptomatic individuals with spontaneous or drug-induced type 1 ECG phenotype of BS display a benign clinical course during long-term follow-up.

Epsilon-like waves and ventricular conduction abnormalities in subjects with type 1 ECG pattern of Brugada syndrome.

BACKGROUND: Previous studies have demonstrated an overlap between the arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) and Brugada syndrome (BS). Conduction delay in the right ventricle has been demonstrated in both entities. OBJECTIVE: This study investigated specific ARVC/D electrocardiographic (ECG) markers in subjects with spontaneous or drug-induced type 1 ECG pattern of BS. METHODS: The study population consisted of 47 apparently healthy individuals (38 men, mean age 44.1 ± 13.3 years) with spontaneous (n = 17) or drug-induced (n = 30) type 1 ECG phenotype of BS. The clinical records of these individuals were retrospectively analyzed. RESULTS: Fifteen subjects (31.9%) were symptomatic, with a history of syncope. A family history of BS or sudden cardiac death was reported in 10 (21.3%) and 8 (17.0%) cases, respectively. Epsilon-like waves in leads V1-V3 were observed in 6 subjects (12.7%). Epsilon-like waves were seen in spontaneous type 1 ECGs in 2 cases and after sodium channel blocking test in 4 cases. In baseline ECGs, localized prolongation (>110 ms) of the QRS complex in leads V1-V3, QRS duration ratio in (V1+V2+V3)/(V4+V5+V6) ≥ 1.2, and prolonged S wave upstroke (>55 ms) in leads V1-V3 were seen in 48.8%, 29.8%, and 40.4% of subjects, respectively. Epsilon-like waves and delayed S wave upstroke were more commonly observed in subjects with family history of BS (P = .014 and P = .038, respectively). CONCLUSION: Specific ECG markers that reflect ventricular conduction delay in ARVC/D are commonly observed in subjects with spontaneous or drug-induced type 1 ECG pattern of BS as well. These depolarization abnormalities may be related to subtle underlying structural abnormalities.

Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway.

OBJECTIVE: The present study aimed to evaluate the diagnostic value of specific ECG markers in the differentiation of common type atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) via a concealed accessory pathway. METHODS: One hundred and ten ECGs with paroxysmal narrow QRS complex, short RP tachycardia were evaluated. Subjects with overt ventricular pre-excitation during sinus rhythm were excluded from the study. The mechanism of arrhythmia was established during the electrophysiological study and confirmed by the efficacy of radiofrequency ablation. RESULTS: Of the 110 patients, 74 displayed common type AVNRT and 36 AVRT. Predictors of AVNRT were the presence of pseudo r'-waves in lead V1 [sensitivity 39.19%; specificity 97.14%; positive predictive value (PPV) 96.67%; negative predictive value (NPV) 43.04%] and pseudo S-waves in inferior leads (sensitivity 28.38%; specificity 94.29%; PPV 91.30%; NPV 38.37%). In the setting of visible P-waves, an RP interval < or =90 ms favoured the diagnosis of AVNRT (sensitivity 57.14%; specificity 80.65%). Predictors of AVRT were QRS alternans (sensitivity 50%; specificity 89.19%; PPV 69.23%; NPV 78.57%) as well as ST-segment alterations during tachycardia. The overall sensitivity, specificity, PPV and NPV of ST-segment depression for discriminating AVRT from AVNRT were 97.22%, 58.11%, 53.03%, 97.73%, respectively. Similarly, the sensitivity, specificity, PPV and NPV of ST-segment elevation in lead aVR were 94.44%, 58.11%, 52.31%, and 95.56%, respectively. Multiple logistic regression analysis showed that ST-segment depression [(odds ratio (OR): 12.67, 95% confidence interval (CI): 1.77-90.81, P = 0.011)] and QRS alternans (OR: 9.43, 95% CI: 1.38-64.37, P = 0.022) displayed the highest predictive ability favouring the diagnosis of AVRT. CONCLUSIONS: Twelve-lead ECG parameters may help to differentiate the mechanism of supraventricular tachycardia prior to the ablation procedure.

QRS complex abnormalities in subjects with idiopathic ventricular fibrillation.

Recent data point to a high incidence of early repolarization abnormalities among patients with idiopathic ventricular fibrillation (IVF). ECG data from 11 patients with idiopathic IVF were evaluated for the presence of initial (slurring or notching of the ascending limb of the R-wave that resembles a "pseudo" delta-wave) and terminal (slurring or notching of the descending limb of the R-wave resembling the early repolarization pattern) QRS complex abnormalities in at least two contiguous leads. The control group comprised 101 age- and gender-matched healthy individuals without structural heart disease in whom the presence of an accessory pathway was excluded during electrophysiological study. Initial QRS complex abnormalities in the setting of a normal PR interval were more frequent in subjects with IVF than in control population (36.4% vs. 8.9%, p=0.023). Although not statistically significant, an early repolarization pattern was also more common among patients with IVF (27.3% vs. 12.9%, p=0.192). Among patients with IVF, there is an increased prevalence of initial and terminal QRS complex abnormalities.

Pressure-guided cryoballoon isolation of the pulmonary veins for the treatment of paroxysmal atrial fibrillation.

BACKGROUND: Pulmonary vein (PV) isolation using a balloon-mounted cryoablation system is a new technology for the percutaneous treatment of atrial fibrillation (AF). Complete PV occlusion during balloon ablation has been shown to predict successful electrical isolation. The aim of this study was to correlate mechanical PV occlusion with changes in a pressure curve recorded at the distal tip of the cryoballoon catheter. METHODS AND RESULTS: We analyzed 51 PVs in 12 patients (61 +/- 6 years old) with paroxysmal AF. At first, PV occlusion via the cryoballoon was documented by changes in the pressure curve. Once the PV is occluded, the pressure curve registered in the vein converts from a left atrial pressure curve to a pulmonary artery pressure curve: the PV wedge curve. Occlusion was then confirmed by transesophageal echocardiography (TEE). Following 2 cryoablation applications, electrical PV isolation was assessed with a circumferential mapping catheter. Under the exclusive guidance of changes in the pressure curve at the tip of the cryoballoon, mechanical occlusion confirmed by TEE was achieved in 47 of 51 PVs (92%). Three PVs required further TEE guidance to achieve occlusion. All 50 occluded veins were electrically isolated after cryoablation. One right inferior vein, which could not be occluded with the balloon, displayed conduction post cryoablation and was isolated by focal ablation. CONCLUSIONS: Occlusion and electrical isolation of PVs during cryoballoon ablation can be predicted by the appearance of a PV wedge curve at the tip of the catheter. This new straightforward parameter may facilitate the procedure.

Tpeak-Tend interval and Tpeak-Tend/QT ratio as markers of ventricular tachycardia inducibility in subjects with Brugada ECG phenotype.

AIMS: The present study investigated whether several ECG markers of ventricular repolarization are associated with ventricular tachycardia/fibrillation (VT/VF) inducibility in subjects with type 1 ECG pattern of Brugada syndrome (BS). METHODS AND RESULTS: The clinical data of 23 individuals (19 males, age 42.69 +/- 14.63) with spontaneous (n = 10) or drug-induced (n = 13) type 1 ECG pattern of BS who underwent programmed ventricular stimulation were analysed. Sustained VT/VF was induced in 17 subjects (74%) and was significantly associated with the presence of spontaneous type 1 ECG of BS (P = 0.012). Among the studied ECG repolarization markers, subjects with inducible VT/VF displayed an increased T(peak)-T(end) interval in leads V(2) (88.82 +/- 15.70 vs. 78.33 +/- 4.08 ms, P = 0.02) and V(6) (76.33 +/- 10.08 vs. 66.66 +/- 5.16 ms, P = 0.04) and a greater T(peak)-T(end)/QT ratio in lead V(6) (0.214 +/- 0.028 vs. 0.180 +/- 0.014, P = 0.009) compared with those without arrhythmias. Ventricular tachycardia/fibrillation inducibility was not associated with arrhythmic events during a mean follow-up period of 4.61 +/- 2.14 years (P = 0.739). CONCLUSION: The T(peak)-T(end) interval and T(peak)-T(end)/QT ratio were associated with VT/VF inducibility in BS. The utility of T(peak)-T(end)/QT ratio as a new marker of arrhythmogenesis in BS requires further studies, including a large number of patients.

Cryoballoon pulmonary vein isolation guided by transesophageal echocardiography: novel aspects on an emerging ablation technique.

BACKGROUND: Pulmonary vein (PV) isolation using a balloon-mounted cryoablation system is a new technology for the percutaneous treatment of atrial fibrillation (AF). Transesophageal echocardiography (TEE) allows real-time visualization of cryoballoon positioning and successful vein occlusion via color Doppler. We hypothesized that PV mechanical occlusion monitored with TEE could predict effective electrical isolation. METHODS: We studied 124 PVs in 30 patients. Under continuous TEE assessment, a cryoballoon was placed in the antrum of each PV aiming for complete PV occlusion as documented by color Doppler. At the end of the procedure, PV electrical isolation was evaluated using a circumferential mapping catheter. RESULTS: Of the 124 PVs studied, 123 (99.2%) could be visualized by TEE: the antrum was completely visualized in 80 of them (64.5%), partially in 36 (29.0%), and only disappearance of proximal flow could be observed in the remaining 7 PVs (5.7%). Vein occlusion could be achieved in 111 of the 123 (90.2%) visualized PVs. Postinterventional mapping demonstrated electrical isolation in 109 of 111 occluded PVs (positive predictive value 98.2%) and only in 1 of 12 nonoccluded PVs (negative predictive value 91.7%, P < 0.001). After a mean follow-up of 7.4 +/- 3.7 months, 73.3% of patients remained in sinus rhythm without antiarrhythmic drugs. CONCLUSION: Color Doppler documented PV occlusion during cryoballoon ablation can predict effective electrical isolation.

Predictors of atrial tachyarrhythmias in subjects with type 1 ECG pattern of Brugada syndrome.

BACKGROUND: Previous studies have demonstrated a high incidence of atrial tachyarrhythmias (ATs) in patients with Brugada syndrome (BS). The present study aimed to investigate whether various 12-lead electrocardiogram (ECG) and electrophysiological parameters may help to differentiate subjects with a high probability to develop ATs. METHODS AND RESULTS: The clinical records of 38 individuals (31 males, age 44.4 +/- 13.9) with spontaneous (n = 15) or ajmaline-induced (n = 23) type 1 ECG pattern of BS were analyzed. During a mean follow-up period of 4.6 +/- 2.2 years, nine subjects suffered ATs (24%). Six subjects displayed paroxysmal atrial fibrillation and three typical atrial flutter. Among the studied 12-lead ECG parameters, subjects with ATs exhibited increased values of P-wave duration in lead II, P-wave dispersion, PR interval in leads II, QRS duration in leads II and V(2), Tpeak-end interval in lead II, and Tpeak-end dispersion of the 12 leads in relation to those without ATs (P < 0.05). Among the assessed electrophysiological parameters, atrial-His (AH) and His-ventricular (HV) intervals were significantly prolonged in subjects with ATs (P < 0.05). Multiple Cox proportional hazards analysis revealed that P-wave duration in lead II, P-wave dispersion, Tpeak-end in lead II, Tpeak-end dispersion of the 12 leads, as well as AH and HV intervals are independent predictors of ATs in subjects with BS (P < 0.05). Cut-off point analysis showed that an HV interval>or=56 ms displayed the highest predictive ability (P < 0.01). CONCLUSION: Our findings demonstrate that simple 12-lead ECG and electrophysiological parameters may easily be applied to identify high-risk subjects with BS ECG phenotype to develop ATs.

Adenosine sensitive focal atrial tachycardia originating from the non-coronary aortic cusp.

We report on the characteristics and the ablation procedure of a focal atrial tachycardia originating from the non-coronary aortic cusp. The electrophysiological features of the tachycardia included: (i) incessant pattern; (ii) easy induction and termination by atrial stimulation; (iii) earliest right atrial activation at the para-hisian area; and (iv) termination by adenosine. Left-sided mapping revealed the earliest atrial activation during the tachycardia at the non-coronary aortic cusp. Radiofrequency energy application at this site successfully terminated the tachycardia. Mapping of the non-coronary aortic cusp should always be considered when the earliest right atrial activation is recorded at the para-hisian area in order to avoid the risk of atrioventricular block by inappropriate ablation near the His-bundle region.

Pre-ablative predictors of atrial fibrillation recurrence following pulmonary vein isolation: the potential role of inflammation.

AIMS: An increasing body of evidence has demonstrated the essential role of inflammation in the genesis and maintenance of atrial fibrillation (AF). The aim of the present study was to investigate whether success or failure of electrical pulmonary vein isolation (PVI) in patients with AF is related with the presence of a pre-ablative inflammatory state as determined by known clinical parameters and conventional markers of inflammation including high-sensitivity C-reactive protein, white blood cell (WBC) count, and fibrinogen. METHODS AND RESULTS: Seventy-two patients with paroxysmal (64%) or persistent AF (36%) underwent successful electrical PVI. The mean duration of arrhythmia was 5.5 +/- 2.9 years. After a mean follow-up period of 12.5 +/- 5.7 months, 44 patients (61%) were in sinus rhythm. In univariate Cox proportional hazard regression analysis, hypertension, body mass index (BMI), left ventricular ejection fraction, left ventricular end-diastolic diameter, left atrial diameter (LAD), WBC count, and high-sensitivity C-reactive protein were significantly associated with AF recurrence (P < 0.05). In multivariate Cox proportional hazard regression analysis, hypertension [hazard ratio (HR) 3.127; 95% confidence interval (CI) 1.269-7.706, P = 0.013], LAD (HR 1.077; 95% CI 1.014-1.144, P = 0.015), and WBC count (HR 1.423; 95% CI 1.067-1.897, P = 0.016) were independent pre-ablative predictors of AF recurrence following PVI. CONCLUSION: Conventional markers of the inflammatory cascade such as WBC count and high-sensitivity C-reactive protein as well as elements of the metabolic syndrome such as hypertension and increased BMI were significantly associated with AF recurrence. The impact of a pre-ablative inflammatory state in the overall success rate of PVI needs further elucidation.

Prevalence of early repolarization pattern in inferolateral leads in patients with Brugada syndrome.

BACKGROUND: Recent data have shown a high incidence of the early repolarization pattern confined in inferolateral leads in patients with idiopathic ventricular fibrillation. OBJECTIVES: The purpose of the present study was to investigate the prevalence and the prognostic significance of the early repolarization pattern in inferolateral leads in patients with Brugada syndrome. METHODS: Clinical, genetic, and electrophysiologic data from 290 individuals (223 males, mean age 48.3 +/- 14.2 years) with a spontaneous or drug-induced type 1 electrocardiogram (ECG) pattern of Brugada syndrome and structurally normal hearts were analyzed. Twelve-lead ECGs were evaluated for the presence of early repolarization pattern, which was defined as J-point elevation of at least 0.1 mV from baseline in at least two inferior or lateral leads. Follow-up data were obtained for all subjects. RESULTS: An early repolarization pattern manifested as notched or slurred J-point elevation mainly in lateral leads was observed in 35 subjects (12%). The prevalence of the early repolarization pattern was significantly higher in male subjects (P = .004). During a mean follow-up period of 44.9 +/- 27.5 months, 22 subjects (8%) displayed an arrhythmic event including sudden cardiac death. There were no significant differences regarding spontaneous ECG type of Brugada syndrome, symptoms, family history of sudden cardiac death, and positive genetic test between subjects with and without the early repolarization pattern. The presence of early repolarization pattern was not associated with arrhythmic events during follow-up (Hazard ratio [HR] 1.090; 95% confidence interval 0.349-3.403; P = .882). CONCLUSION: The early repolarization pattern in inferolateral leads is not an uncommon finding in Brugada syndrome. In our population, the early repolarization features were not associated with a worse outcome in subjects with Brugada syndrome.

Catheter ablation of recipient-to-donor atrioatrial conduction with Wenckebach-like phenomenon after orthotopic heart transplantation.

This report describes a case of atrial tachycardia in the recipient atrium manifested electrocardiographically as typical atrial flutter in the donor atrium due to atrioatrial conduction delay with Wenckebach-like phenomenon at the anastomotic line. Radio-frequency energy application resulted in immediate recipient-to-donor conduction block.

Necessity for surgical revision of defibrillator leads implanted long-term: causes and management.

BACKGROUND: Defibrillator lead malfunction is a potential long-term complication in patients with an implantable cardioverter-defibrillator (ICD). The aim of this study was to determine the incidence and causes of lead malfunction necessitating surgical revision and to evaluate 2 approaches to treat lead malfunction. METHODS AND RESULTS: We included 1317 consecutive patients with an ICD implanted at 3 European centers between 1993 and 2004. The types and causes of lead malfunction were recorded. If the integrity of the high-voltage part of the lead could be ascertained, an additional pace/sense lead was implanted. Otherwise, the patients received a new ICD lead. Of the 1317 patients, 38 experienced lead malfunction requiring surgical revision and 315 died during a median follow-up of 6.4 years. At 5 years, the cumulative incidence was 2.5% (95% confidence interval, 1.5 to 3.6). Lead malfunction resulted in inappropriate ICD therapies in 76% of the cases. Implantation of a pace/sense lead was feasible in 63%. Both lead revision strategies were similar with regard to lead malfunction recurrence (P=0.8). However, the cumulative incidence of recurrence was high (20% at 5 years; 95% confidence interval, 1.7 to 37.7). CONCLUSIONS: ICD lead malfunction necessitating surgical revision becomes a clinically relevant problem in 2.5% of ICD recipients within 5 years. In selected cases, simple implantation of an additional pace/sense lead is feasible. Regardless of the chosen approach, the incidence of recurrent ICD lead-related problems after lead revision is 8-fold higher in this population.

Pulmonary edema after extensive radiofrequency ablation for atrial fibrillation.

BACKGROUND: More extensive ablation strategies for the treatment of atrial fibrillation (AF) have increased success rates but are associated with new and sometimes serious complications. We describe a new complication after extensive radiofrequency (RF) ablation in the left atrium (LA) for persistent AF. METHODS AND RESULTS: Electroanatomic guided circumferential ablation around both ipsilateral pulmonary veins (PV) was performed with the endpoint of complete conduction block. When necessary, supplementary RF applications were added, including ablation of complex fractionated potentials and/or isolation of other thoracic veins and/or linear left atrial lesions. RF energy was delivered via an irrigated tip catheter with a maximum power of 30-35 W. Four out of 120 patients undergoing extensive RF ablation for persistent AF (including two patients with additional LA substrate modification) developed dyspnea, bilateral pulmonary edema, and signs of a systemic inflammatory response syndrome (SIRS) (rise in body temperature, leukocyte count, and C-reactive protein (CRP levels) 18-48 hours after the procedure. There were no signs of PV stenosis, focal lung injury, left ventricular dysfunction, circulatory failure, or infection. All patients had complete recovery with supportive therapy within 3-4 days after the onset of symptoms. CONCLUSIONS: Extensive LA radiofrequency ablation bears the risk of a severe pulmonary edema. Although the precise mechanism is elusive, clinical features point toward a systemic inflammatory response.

Small or large isolation areas around the pulmonary veins for the treatment of atrial fibrillation? Results from a prospective randomized study.

BACKGROUND: Pulmonary vein (PV) isolation is a promising new treatment for atrial fibrillation (AF). We hypothesized that isolation of large areas around both ipsilateral PVs with verification of conduction block is more effective than the isolation of each individual PV. METHODS AND RESULTS: A total of 110 patients, 67 with paroxysmal AF and 43 with persistent AF, were randomly assigned to undergo either isolation of each individual PV or isolation of large areas around both ipsilateral PVs. The isolation of each individual PV was an electrophysiologically guided, ostial segmental ablation with a 64-pole basket catheter or a 20-pole circular mapping catheter (group I). Isolation of large areas was performed around the 2 ipsilateral veins with a nonfluoroscopic navigation system and a circular 20-pole mapping catheter for verification of conduction block (group II). In both groups, an irrigated-tip ablation catheter (25 to 35 W) was used to achieve complete isolation. Procedure and ablation times were longer in group II, whereas fluoroscopic time was significantly shorter (P < or = 0.001). After a follow-up period of 15+/-4 months, 27 patients in group I (49%) and 37 patients in group II (67%) remained free of symptoms of AF and had no AF or atrial flutter during repetitive Holter monitoring without antiarrhythmic drug treatment after a single procedure (P < or = 0.05). CONCLUSIONS: The rate of success was significantly higher and fluoroscopy times were significantly lower in the group with large isolation areas around both ipsilateral PVs than in those who underwent individual PV isolation.