A prospective randomized study comparing isolation of the arrhythmogenic vein versus all veins in paroxysmal atrial fibrillation.
ABSTRACT: BACKGROUND:Ablation procedures in patients with paroxysmal atrial fibrillation (PAF) includes isolation of all pulmonary veins (PVs). We hypothesized that an approach using an algorithm to detect arrhythmogenic PVs (aPVs) might lead to shorter procedure duration (PD) and fewer proarrhythmic effects (PE). HYPOTHESIS:Isolation of the aPVs only leads to a reduced PD, reduced PEs, and fewer adverse events, with a success rate comparable to the standard all-PV approach. METHODS:In this prospective trial, 207 patients with PAF were randomized to undergo isolation of the aPV (AG group, n?=?105) or isolation of all PVs (VG group, n?=?102). The aPV was identified by atrial fibrillation (AF) induction, focal discharge, or short local PV decremental conduction during PV pacing. Patients were followed with repetitive 7-day Holter electrocardiograms (ECGs) after 3, 6, and 12?months in our arrhythmia clinic. RESULTS:In 97% of patients, at least 1 aPV was identified (mean, 2.1). PD did not differ significantly (152.3?±?57.1?minutes vs 162?±?68?minutes, P = 0.27) between the groups, but the number of radiofrequency (RF) applications and fluoroscopy time (FT) and dose were significantly lower in the AG group than in the VG group. The occurrence of PE (new-onset atrial tachycardia) and adverse events (AE) did not differ between the 2 groups (P = 0.1). Sinus rhythm off antiarrhythmic medication (documented on 7-day Holter ECGs) 12?months after a single procedure was achieved in 53% in the AG group and 59% in the VG group (P = 0.51). CONCLUSIONS:Isolation of the aPVs detected by a straightforward algorithm leads to similar success rates compared to a standard all-PV approach with regard to PD, AE, or PE and is associated with less RF and a shorter FT.
Project description:The muscular discontinuities at the pulmonary vein (PV)-left atrial (LA) junction are known. The high-density mapping may help to find the muscular discontinuity. This study evaluated the efficacy of a partial antral ablation for a pulmonary vein (PV) isolation using high density (HD) mapping. A total of 60 drug-refractory atrial fibrillation (AF) patients undergoing catheter ablation were enrolled. The detailed activation mapping of each PV and LA junction was performed using an HD mapping system, and each PV segment's activation pattern was classified into a "directly-activated from the LA" or "passively-activated from an adjacent PV segment" pattern. The antral ablations were performed at the directly-activated PV segments only when the PV had "passively-activated segments". If the PV did not contain passively-activated segments, a circumferential antral ablation was performed on those PVs. A "successful partial antral ablation" was designated if the electrical isolation of targeted PV was achieved by ablation at the directly-activated segments only. If the isolation was not achieved even though all directly-activated segments were ablated, a "failed partial antral ablation" was designated, and then a circumferential ablation was performed. Among 240 PVs, passively-activated segments were observed in 140 (58.3%) PVs. Both inferior PVs had more passively-activated segments than superior PVs, and the posteroinferior segments had the highest proportion of passive activation. The overall rate of successful partial antral ablation was 85%. The atrial tachyarrhythmia recurrence was observed in 10 patients (16.7%) at 1-year. HD mapping allowed the evaluation of the detailed activation patterns of the PVs, and passively-activated segments may represent muscular discontinuity. Partial antral ablation of directly-activated antral segments only was feasible and effective for a PVI.
Project description:Viruses in the family <i>Papillomaviridae</i> have circular dsDNA genomes of approximately 5.7-8.6 kb that are packaged within non-enveloped, icosahedral capsids. The known papillomavirus (PV) representatives infect vertebrates, and there are currently more than 130 recognized PV species in more than 50 genera. We identified 12 novel avian papillomavirus (APV) types in wild birds that could represent five distinct species and two genera. Viruses were detected in paired oropharyngeal/cloacal swabs collected from six bird species, increasing the number of avian species known to harbor PVs by 40%. A new duck PV (DuPV-3) was found in mallard and American black duck (27.6% estimated prevalence) that was monophyletic with other known DuPVs. A single viral type was identified in Atlantic puffin (PuPV-1, 9.8% estimated prevalence), while a higher genetic diversity was found in other Charadriiformes. Specifically, three types [gull PV-1 (GuPV-1), -2, and -3] were identified in two gull species (estimated prevalence of 17% and 2.6% in American herring and great black-backed gull, respectively), and seven types [kittiwake PV-1 (KiPV-1) through -7] were found in black-legged kittiwake (81.3% estimated prevalence). Significantly higher DuPV-3 circulation was observed in spring compared to fall and in adults compared to juveniles. The studied host species' tendencies to be in crowded environments likely affect infection rates and their migratory behaviors could explain the high viral diversity, illustrating how host behavior can influence viral ecology and distribution. For DuPV-3, GuPV-1, PuPV-1, and KiPV-2, we obtained the complete genomic sequences, which showed the same organization as other known APVs. Phylogenetic analyses showed evidence for virus-host co-divergence at the host taxonomic levels of family, order, and inter-order, but we also observed that host-specificity constraints are relaxed among highly related hosts as we found cross-species transmission within ducks and within gulls. Furthermore, the phylogeny of viruses infecting the Charadriiformes did not match the host phylogeny and gull viruses formed distinct monophyletic clades with kittiwake viruses, possibly reflecting past host-switching events. Considering the vast PV genotype diversity in other hosts and the large number of bird species, many more APVs likely remain to be discovered.
Project description:BACKGROUND:Obstructive sleep apnea (OSA) is associated with atrial remodeling, atrial fibrillation (AF), and increased incidence of arrhythmia recurrence after pulmonary vein (PV) isolation. We aimed to characterize the atrial substrate, including AF triggers in patients with paroxysmal AF and OSA. METHODS AND RESULTS:In 86 patients with paroxysmal AF (43 with ?moderate OSA [apnea-hypopnea index ?15] and 43 without OSA [apnea-hypopnea index <5]), right atrial and left atrial voltage distribution, conduction velocities, and electrogram characteristics were analyzed during atrial pacing. AF triggers were examined before and after PV isolation and targeted for ablation. Patients with OSA had lower atrial voltage amplitude (right atrial, P=0.0005; left atrial, P=0.0001), slower conduction velocities (right atrial, P=0.02; left atrial, P=0.0002), and higher prevalence of electrogram fractionation (P=0.0001). The areas of atrial abnormality were consistent among patients, most commonly involving the left atrial septum (32/43; 74.4%). At baseline, the PVs were the most frequent triggers for AF in both groups; however, after PV isolation patients with OSA had increased incidence of additional extra-PV triggers (41.8% versus 11.6%; P=0.003). The 1-year arrhythmia-free survival was similar between patients with and without OSA (83.7% and 81.4%, respectively; P=0.59). In comparison, control patients with paroxysmal AF and OSA who underwent PV isolation alone without ablation on extra-PV triggers had increased risk of arrhythmia recurrence (83.7% versus 64.0%; P=0.003). CONCLUSIONS:OSA is associated with structural and functional atrial remodeling and increased incidence of extra-PV triggers. Elimination of these triggers resulted in improved arrhythmia-free survival.
Project description:BACKGROUND:The second-generation cryoballoon significantly improves outcome of pulmonary vein isolation (PVI) but may cause more complications than the first generation. Currently, no consensus regarding optimal cryoballoon application time exists. The 123-study aimed to assess the minimal cryoballoon application duration necessary to achieve PVI (primary endpoint) and the effect of application duration on prevention of phrenic nerve injury (PNI). METHODS:Patients <75 years of age with paroxysmal atrial fibrillation, normal PV anatomy, and left atrial size <40 cc/m² or <50 mm were randomized to two applications of different duration: "short," "medium," or "long." A total of 222 patients were enrolled, 74 per group. RESULTS:Duration per application was 105 (101-108), 164 (160-168), and 224 (219-226) s and isolation was achieved in 79, 89, and 90% (P < 0.001) of the PVs after two applications in groups short, medium, and long, respectively. Only for the left PVs, the success rate of the short group was significantly less compared to the medium- and long-duration groups (P < 0.001). PNI during the procedure occurred in 19 PVs (6.5%) in the medium and in 20 PVs (6.8%) in the long duration groups compared to only five PVs (1.7%) in the short duration group (P < 0.001). CONCLUSIONS:Short cryoballoon ablation application times, less than 2 min, did affect the success for the left PVs but not for the right PVs and resulted in less PNI. A PV tailored approach with shorter application times for the right PVs might be advocated.
Project description:<h4>Background</h4>Atrial fibrillation (AF) is the most common supraventricular arrhythmia, characterized by disorganized atrial electrical activity, maintained by localized arrhythmogenic atrial drivers. Pulmonary vein isolation (PVI) allows to exclude PV-related drivers. However, PVI is less effective in patients with additional extra-PV arrhythmogenic drivers.<h4>Objectives</h4>To discriminate whether AF drivers are located near the PVs vs extra-PV regions using the noninvasive 12-lead electrocardiogram (ECG) in a computational and clinical framework, and to computationally predict the acute success of PVI in these cohorts of data.<h4>Methods</h4>AF drivers were induced in 2 computerized atrial models and combined with 8 torso models, resulting in 1128 12-lead ECGs (80 ECGs with AF drivers located in the PVs and 1048 in extra-PV areas). A total of 103 features were extracted from the signals. Binary decision tree classifier was trained on the simulated data and evaluated using hold-out cross-validation. The PVs were subsequently isolated in the models to assess PVI success. Finally, the classifier was tested on a clinical dataset (46 patients: 23 PV-dependent AF and 23 with additional extra-PV sources).<h4>Results</h4>The classifier yielded 82.6% specificity and 73.9% sensitivity for detecting PV drivers on the clinical data. Consistency analysis on the 46 patients resulted in 93.5% results match. Applying PVI on the simulated AF cases terminated AF in 100% of the cases in the PV class.<h4>Conclusion</h4>Machine learning-based classification of 12-lead-ECG allows discrimination between patients with PV drivers vs those with extra-PV drivers of AF. The novel algorithm may aid to identify patients with high acute success rates to PVI.
Project description:A 66-year-old female, whom received a pulmonary vein (PV) isolation (PVAI) with linear ablation of the carina lines between the superior and inferior PVs of both the right and left PVs for atrial fibrillation (AF), was admitted to receive a radiofrequency catheter ablation (RFCA) of symptomatic drug-refractory atrial tachycardia (AT). The EnSiteTM analysis by the AdvisorTM HD Grid catheter during the AT could easily detect that the carina between the right superior and inferior PVs exhibited a low voltage area (< 0.5 mV), in addition to the fact that the electrical activation turned around the right PVs in a figure 8, even though mapping was performed during AT. This AT was steadily terminated, after commencing the radiofrequency energy delivery to the carina of the right PVs.
Project description:<h4>Background</h4>Pulmonary vein (PV) reconnection is the main cause of atrial fibrillation (AF) recurrence. This study aimed to examine the effect of first-pass PV isolation (PVI) on PV reconnection frequency during the procedure and on AF ablation outcomes.<h4>Methods</h4>This retrospective study included 446 patients with drug-refractory AF (370 men, aged 64 ± 10 years) who underwent initial PVI using an open-irrigated contact force catheter between January 2015 and October 2016. We investigated the effect of first-pass PVI on PV reconnection during spontaneous PV reconnection and dormant conduction after an adenosine triphosphate challenge.<h4>Results</h4>First-pass PVI was achieved in 69% (617/892) of ipsilateral PVs, of which we observed PV reconnection during the procedure in 134 (22%) PVs. This value was significantly lower than that observed in those without first-pass PVI (50%, 138/275) (<i>P</i> < .0001). We divided the subjects into two groups based on the presence or absence of first-pass PVI in at least one of two ipsilateral PVs: first-pass (n = 383, 86%) and non-first-pass groups (n = 63, 14%). The 2-year AF recurrence-free rate was significantly higher in the first-pass group than in the other group (75% vs 59%, log-rank <i>P</i> = .032). In 78 patients with repeat AF ablation, the PV reconnection rate in the second procedure was significantly lower in PVs that had first-pass isolation in the first procedure (34% vs 73%, <i>P</i> < .0001).<h4>Conclusions</h4>Absence of first-pass PVI was associated with a higher frequency of spontaneous PV reconnection and dormant conduction and poor ablation outcomes. First-pass isolation may be a useful marker for better PVI durability.
Project description:<h4>Introduction</h4>Approximately 18% of patients with atrial fibrillation (AF) undergo a repeat ablation within 12 months after their index ablation. Despite the high prevalence, comparative studies on nonpulmonary vein (PV) target strategies in repeat AF ablation are scarce. Here, we describe 12 months efficacy of non-PV and PV target ablations as a repeat ablation strategy.<h4>Methods</h4>A multicentre retrospective, descriptive study was conducted with data of 280 patients who underwent repeat AF ablation. The ablation strategy for repeat ablation was at the operators' discretion. Non-PV target ablation (n = 140) included PV reisolation, posterior wall isolation, mitral line, roofline, and/or complex fractionated atrial electrogram ablation. PV target ablation (n = 140), included reisolation and/or wide atrium circumferential ablation. Patients' demographics and rhythm outcomes during 12 months follow-up were analyzed.<h4>Results</h4>At 12 months, more atrial tachyarrhythmias were observed in the non-PV target group (48.6%) compared to the PV target group (29.3%, p = .001). Similarly, a significantly higher AF and atrial tachycardia (AT) recurrence rate was observed after non-PV target ablation compared to PV target ablation (36.4% vs. 22.1% and 22.9% vs. 10.7%). After adjustment, a significantly higher risk of AT recurrence remained in the non-PV target group. Both groups significantly de-escalated antiarrhythmic drug use; de-escalation was more profound after PV target ablation. Patients with isolated PVs during non-PV target ablation had a significantly higher risk for AF recurrence than those with reconnected PVs.<h4>Conclusion</h4>Compared to PV target ablation, non-PV target repeat ablation did not improve outcomes after 12 months and was independently associated with an increased risk for AT recurrences.
Project description:Avipoxviruses (APVs) are among the most complex viruses that infect a wide range of birds' species. The infection by APVs is often associated with breathing and swallowing difficulties, reduced growth, decreased egg production, and high mortalities in domestic poultry. In the present study, 200 cutaneous nodular samples were collected from different avian species (chicken, pigeon, turkey, and canary) suspected to be infected with APVs from Dakahlia Governorate, Egypt. Pooled samples (n = 40) were prepared and inoculated in embryonated chicken eggs (ECEs). APVs were then identified by polymerase chain reaction (PCR) and sequence analysis of the APV P4b gene. Furthermore, the forty strains of APVs were screened for the presence of reticuloendotheliosis virus (REV)-5'LTR in their genomes. Interestingly, the phylogenic tree of the APV P4b gene was separated into 2 clades: clade 1, in which our fowlpox virus (FWPV), turkeypox virus (TKPV), and canarypox virus (CNPV) isolates were grouped, along with reference FWPVs and TKPVs retrieved from GenBank, whereas, in clade2, the pigeonpox virus (PGPV) isolate was grouped with PGPVs retrieved from GenBank. Likewise, REV-5'LTR was amplified from 30 strains isolated from chicken, turkey, and canary, while PGPV strains were free from REV-5'LTR integration. To the best of our knowledge, this study involved the detection and characterization of REV-5'LTR insertions in the APVs field isolates in Egypt for the first time. Given the above information, further future research seems recommended to understand the impact of the resulting REV-5'LTR insertions on the pathogenesis, virulence, and inadequate vaccine protection against APVs.
Project description:Background:Pulmonary vein isolation (PVI) with multielectrode duty-cycled radiofrequency (PVAC) has been shown to be effective in the treatment of atrial fibrillation (AF). We describe pulmonary vein (PV) reconnection at repeat ablation in patients with AF recurrence after PVAC PVI and analyze the correlation between the time of AF recurrence and the observed PV reconnection patterns. Methods:Eighty-five patients undergoing a redo PVI for recurrent AF 9.2 ± 3.8 months after an initial PVAC PVI procedure was retrospectively enrolled. Results:A total of 93% had PV reconnections with a mean of 2.97 ± 1.2 reconnected PVs/patients and 75% of formerly isolated PVs were found reconnected. The highest reconnection rates (94%) were observed for left common trunks (CTs). A total of 33% patients had three and four reconnected PVs, respectively, while 7% were without PV reconnection. There was a moderate but significant negative correlation between the time of AF recurrences and the extending of PV reconnections at redo PVI for patients with proven PV reconnection (r = -0.32, P = 0.005), whereas five out of six patients without PV reconnection had recurrences within the first 9 months after PVI. Conclusions:At redo ablation most patients with recurrence of AF after PVAC PVI had PV reconnection(s). Patients with PV reconnection(s) showed a moderate negative correlation between the number of reconnected PVs and the time of AF recurrence with more extensive PV reconnections resulting in earlier PV recurrences after the blanking period. Patients without PV reconnection experienced early AF recurrences, indicating non-PV triggers contribute to AF recurrences in these patients.