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| 2. |
- Haissaguerre, Michel, et al.
(författare)
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Localized sources maintaining atrial fibrillation organized by prior ablation
- 2006
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Ingår i: Circulation. - 0009-7322 .- 1524-4539. ; 113, s. 616-625
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Tidskriftsartikel (refereegranskat)abstract
- Background— Endocardial mapping of localized sources drivingatrial fibrillation (AF) in humans has not been reported.Methods and Results— Fifty patients with AF organizedby prior pulmonary vein and linear ablation were studied. AFwas considered organized if mapping during AF showed irregularbut discrete atrial complexes exhibiting consistent activationsequences for >75% of the time using a 20-pole catheter with5 radiating spines covering 3.5-cm diameter or sequential conventionalmapping. A site or region centrifugally activating the remainingatrial tissue defined a source. During AF with a cycle lengthof 211±32 ms, activation mapping identified 1 to 3 sourcesat the origin of atrial wavefronts in 38 patients (76%) predominantlyin the left atrium, including the coronary sinus region. Electrogramsat the earliest area varied from discrete centrifugal activationto an activity spanning 75% to 100% of the cycle length in 42%of cases, the latter indicating complex local conduction ora reentrant circuit. A gradient of cycle length (>20 ms)to the surrounding atrium was observed in 28%. Local radiofrequencyablation prolonged AF cycle length by 28±22 ms and eitherterminated AF or changed activation sequence to another organizedrhythm. In 4 patients, the driving source was isolated, surroundedby the atrium in sinus rhythm, and still firing at high frequency(228±31 ms) either permanently or in bursts.Conclusions— AF associated with consistent atrial activationsequences after prior ablation emanates mostly from localizedsources that can be mapped and ablated. Some sources harborelectrograms suggesting the presence of localized reentry.
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| 3. |
- Hendriks, Jeroen, et al.
(författare)
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Integrated specialized atrial fibrillation clinics reduce all-cause mortality: post hoc analysis of a randomized clinical trial
- 2019
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Ingår i: Europace. - : OXFORD UNIV PRESS. - 1099-5129 .- 1532-2092. ; 21:12, s. 1785-1792
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Tidskriftsartikel (refereegranskat)abstract
- Aims An integrated chronic care programme in terms of a specialized outpatient clinic for patients with atrial fibrillation (AF), has demonstrated improved clinical outcomes. The aim of this study is to assess all-cause mortality in patients in whom AF management was delivered through a specialized outpatient clinic offering an integrated chronic care programme. Methods and results Post hoc analysis of a Prospective Randomized Open Blinded Endpoint Clinical trial to assess all-cause mortality in AF patients. The study included 712 patients with newly diagnosed AF, who were referred for AF management to the outpatient service of a University hospital. In the specialized outpatient clinic (AF-Clinic), comprehensive, multidisciplinary, and patient-centred AF care was provided, i.e. nurse-driven, physician supervised AF treatment guided by software based on the latest guidelines. The control group received usual care by a cardiologist in the regular outpatient setting. After a mean follow-up of 22months, all-cause mortality amounted 3.7% (13 patients) in the AF-Clinic arm and 8.1% (29 patients) in usual care [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.23-0.85; P = 0.014]. This included cardiovascular mortality in 4 AF-Clinic patients (1.1%) and 14 patients (3.9%) in usual care (HR 0.28; 95% CI 0.09-0.85; P = 0.025). Further, 9 patients (2.5%) died in the AF-Clinic arm due to a non-cardiovascular reason and 15 patients (4.2%) in the usual care arm (HR 0.59; 95% CI 0.26-1.34; P = 0.206). Conclusion An integrated specialized AF-Clinic reduces all-cause mortality compared with usual care. These findings provide compelling evidence that an integrated approach should be widely implemented in AF management.
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| 5. |
- Jais, Pierre, et al.
(författare)
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Stepwise catheter ablation of chronic atrial fibrillation : Importance of descrete anatomic sites for termination
- 2006
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Ingår i: Journal of Cardiovascular Electrophysiology. - : Wiley. - 1540-8167 .- 1045-3873. ; 17:Suppl 3, s. 28-36
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Tidskriftsartikel (refereegranskat)abstract
- Background: Chronic atrial fibrillation (CAF) can be acutely terminated using a combination of approaches targeting thoracic veins, left atrial areas showing rapid/heterogeneous electrical activity, and by linear ablation. This observational study emphasizes the crucial role for conventional endocardial mapping to identify discrete anatomical sites, ablation of which is indispensable for the achievement of atrial fibrillation (AF) termination. Methods: Eighty consecutive patients with CAF underwent catheter ablation using the stepwise approach. Pulmonary vein isolation and roof-line ablation were performed as the initial two steps in all patients. In the presence of locally rapid or heterogeneous activity, ablation was then performed at all sites within the left atrium and coronary sinus (CS) region with the endpoint of local organization or slowing. If AF persisted, the mitral isthmus was targeted. Patients in whom AF terminated during one of these five ablation steps were differentiated from those in whom AF was terminated by radiofrequency ablation at a single discrete anatomic site within 1 minute. Electrograms at discrete anatomic sites of termination were classified according to morphology. Results: Termination of AF was achieved in 69 (86%) patients by ablation alone. In 50 patients (72%), this occurred while following the predetermined ablation schema. In the remaining 19 patients (28%), ablation targeting a discrete site (preferentially located at the CS, the base of left atrial appendage, and the interatrial septum) terminated AF. Such sites were identified by (1) continuous electrical activity and fractionation and (2) bursts of short cycle activity (130–160 msec), centrifugal activation or local activation gradients, indicating sources perpetuating AF. Conclusion: In 28% of patients with termination of CAF, the final successful ablation site is anatomically discrete and displays electrophysiological characteristics that can be effectively identified by point and activation mapping. Failure to identify these sites may significantly reduce the likelihood of termination of CAF by catheter ablation.
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| 6. |
- Lau, Dennis H., et al.
(författare)
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Novel mechanisms in the pathogenesis of atrial fibrillation: practical applications
- 2016
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Ingår i: European Heart Journal. - : OXFORD UNIV PRESS. - 0195-668X .- 1522-9645. ; 37:20, s. 1573-
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Forskningsöversikt (refereegranskat)abstract
- Intensive research over the last few decades has seen significant advances in our understanding of the complex mechanisms underlying atrial fibrillation (AF). The epidemic of AF and related hospitalizations has been described as a rising tide with estimates of the global AF burden showing no sign of retreat. There is urgency for effective translational programs in this field to facilitate more individualized and targeted therapy to modify the abnormal atrial substrate responsible for the perpetuation of this arrhythmia. In this review, we chose to focus on several novel aspects of AF pathogenesis whereby practical applications in clinical practice are currently available or potentially not too far away. Specifically, we explored the contribution of atrial fibrosis, epicardial adipose tissue, autonomic nervous system, hyper-coagulability, and focal drivers to adverse atrial remodelling and AF persistence. We also highlighted the potential practical means of monitoring and targeting these factors to achieve better outcomes in patients suffering from this debilitating illness. Emerging data also support a new paradigm for targeting AF substrate with aggressive risk factor management. Finally, multi-disciplinary integrated care approach has shown great promise in improving cardiovascular outcomes of patients with AF along with potential cost savings.
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| 7. |
- Linz, Dominik, et al.
(författare)
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Longer and better lives for patients with atrial fibrillation : the 9th AFNET/EHRA consensus conference
- 2024
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Ingår i: Europace. - : Oxford University Press. - 1099-5129 .- 1532-2092. ; 26:4
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Tidskriftsartikel (refereegranskat)abstract
- Aims: Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA).Methods and results: Eighty-three international experts met in Munster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF.Conclusions: Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF. Graphical Abstract
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| 8. |
- ONeill, Mark D, et al.
(författare)
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The stepwise ablation approach for chronic atrial fibrillation - evidence for a cumulative effect
- 2006
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Ingår i: Journal of Interventional Cardiac Electrophysiology. - : Springer Science and Business Media LLC. - 1383-875X .- 1572-8595. ; 16, s. 153-167
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Tidskriftsartikel (refereegranskat)abstract
- Treatment options for atrial fibrillation (AF) have evolved from simple, fluoroscopy-guided pulmonary vein isolation for those patients with paroxysmal AF to complex, multi-modality procedures targeting not only anatomic structures but also electrophysiologic phenomena including complex fractionated electrograms, sites of dominant frequency and local non-venous drivers in patients with persistent and permanent AF. The stepwise ablation approach is a novel technique whereby structures contributing to initiation and maintenance of AF are sequentially targeted by radiofrequency ablation. Broadly divided into pulmonary veins, left atrial (LA) roof, left atrium (incorporating all anatomic regions of the chamber), mitral isthmus and non-LA structures, each region is targeted in sequence and the impact of ablation upon the global fibrillatory process assessed by measurement of AF cycle length (AFCL) at a site remote from the ablation target. In addition to pulmonary vein electrical disconnection and demonstrable complete conduction block across the roof and mitral isthmus lines (when performed), ablation is performed at those sites displaying continuous electrical and complex fractionated activity, with the endpoint of local organization, as well as at sites displaying electrograms consistent with focal sources driving AF. Ablation is accompanied by a cumulative increase in the AFCL prior to termination of AF by conversion either directly to sinus rhythm or to an atrial tachycardia which is then mapped conventionally and ablated. There is a ceiling of ablation within the LA beyond which further ablation is unlikely to result in a clinical benefit and should prompt evaluation of the contribution of the right atrium to maintenance of AF. The stepwise approach benefits from the integration of anatomic and electrophysiologic information to achieve a high level of success in termination of chronic AF by catheter ablation.
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| 10. |
- Platonov, Pyotr, et al.
(författare)
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Preferential conduction patterns along the coronary sinus during atrial fibrillation in humans and their modification by pulmonary vein isolation.
- 2011
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Ingår i: Journal of Electrocardiology. - : Elsevier BV. - 1532-8430 .- 0022-0736. ; 44, s. 157-163
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Correlation function analysis applied to endocardial electrograms has earlier been used for analysis of agreement between signals and direction of activation during atrial fibrillation (AF). This study was aimed at evaluating whether preferential activation patterns along the coronary sinus (CS) exist in patients with AF. METHODS: Twenty-seven patients (57 ± 10 years old) admitted for electrophysiological (EP) study (10 patients) and/or AF ablation (17 patients) were studied, 8 with permanent and 19 with persistent AF. Unipolar signals were recorded during 60 seconds from a 10-pole CS catheter during AF at baseline (BL) and after isolation of left and right pulmonary veins and after additional lines in the left atrium (LA) (End). Correlation function analysis was applied to signals from each pair of adjacent electrodes, and graphs of cumulated time delay were made to enable interpretation of direction of activation. RESULTS: Correlation between paired signals was highest in the distal and middle parts of CS and lowest in the proximal CS. In 21 patients, correlation values greater than 0.8 between closely spaced electrodes suggested uniform propagation of the fibrillatory waves. In 18 of 21 patients, preferential conduction pattern along CS was seen. Of those, 15 patients had left-to-right conduction, and 3 had right-to-left conduction. During ablation, atrial fibrillation cycle length increased from 184 ± 32 milliseconds at BL to 193 ± 39 milliseconds after pulmonary vein isolation and 215 ± 39 milliseconds at the end of ablation (P = .03, BL vs End). Because of ablation, preferential conduction along CS changed in 4 patients from left to right at BL to simultaneous CS activation or right to left. In 1 of 3 patients with simultaneous activation at BL, the direction changed to right to left. No direction change was observed in any of the 3 patients with right-to-left activation at BL. CONCLUSIONS: Atrial activation during AF exhibits a high degree of organization in distal and middle CS. Preferential conduction patterns observed in most patients may indicate either relatively dominant stable reentry circuits in the LA or activation spread from a focal source. The changes in preferential conduction during ablation of AF may reflect modification of AF substrate and indicate persistent right atrial sources not affected by ablation in the LA only.
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