Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; methods ; Humans ; Treatment Outcome

BACKGROUNDMajor atrial coronary arteries, including the sinus node artery (SNA), were commonly found in the areas involved in atrial fibrillation (AF) ablation and could cause difficulties in achieving linear block at the left atrial (LA) roof. The SNA is a major atrial coronary artery of the atrial coronary circulation. This study aimed to determine impact of the origin of SNA on recurrence of AF after pulmonary vein isolation (PVI) in patients with paroxysmal AF.

METHODSSeventy-eight patients underwent coronary angiography for suspected coronary heart disease, followed by catheter ablation for paroxysmal AF. According to the origin of SNA from angiographic findings, they were divided into right SNA group (SNA originating from the right coronary artery) and left SNA group (SNA originating from the left circumflex artery). Guided by an electroanatomic mapping system, circumferential pulmonary vein ablation (CPVA) was performed in both groups and PVI was the procedural endpoint. All patients were followed up at 1, 3, 6, 9 and 12 months post-ablation. Recurrence was defined as any episode of atrial tachyarrhythmias (ATAs), including AF, atrial flutter or atrial tachycardia, that lasted longer than 30 seconds after a blanking period of 3 months.

RESULTSThe SNA originated from the right coronary artery in 34 patients (43.6%) and the left circumflex artery in 44 patients (56.4%). Freedom from AF and antiarrhythmic drugs (AADs) at 1 year was 67.9% (53/78) for all patients. After 1 year follow-up, 79.4% (27/34) in right SNA group and 59.1% (26/44) in left SNA group (P = 0.042) were in sinus rhythm. On multivariate analysis, left atrium size (HR = 1.451, 95%CI: 1.240 - 1.697, P < 0.001) and a left SNA (HR = 6.22, 95%CI: 2.01 - 19.25, P = 0.002) were the independent predictors of AF recurrence.

CONCLUSIONSThe left SNA is more frequent in the patients with paroxysmal AF. After one year follow-up, the presence of a left SNA was identified as an independent predictor of AF recurrence after CPVA in paroxysmal AF.

Aged ; Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; Coronary Vessels ; physiopathology ; Female ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; surgery ; Recurrence

BACKGROUNDCircumferential pulmonary vein isolation (CPVI), as the basal ablation strategy for treating atrial fibrillation (AF), not only isolates the connection between the left atrium (LA) and the pulmonary veins (PVs), but also induces extensive atrial endocardia damage. This could have an effect on the sinus pulse conduction in the LA and subsequently result in changes of P-wave characteristics of surface electrocardiogram (ECG).

METHODSFifty consecutive patients underwent CPVI for symptomatic drug-refractory paroxysmal AF. The 12-lead ECGs were recorded one day before CPVI and seven days after CPVI at sinus rhythm by a standard resting ECG device. Measured characteristics of the P-wave consisted of P-wave duration (PWD), P-wave amplitude (PWA), P-wave polarity (PWP), P-wave notch, P-wave dispersion and P-wave index.

RESULTSAfter CPVI, a prevalent decrease of PWD, PWA, and P-wave dispersion was observed; a transition of P-wave polarity was observed in the leads of III, aVL and aVF. The rate of P-wave notch decreased significantly in all leads, especially in the leads of II, III, aVF and V3. Patients with sinus rhythm had a shorter P-wave dispersion and P-wave index and had a lower rate of P-wave notch compared with the patients with recurrent atrial tachyarrhythmia.

CONCLUSIONObservations from using the surface ECG showed that CPVI has instant effects on the electrical conduction in the LA, and several changes of P-wave characteristics associated with development of AF are improved by CPVI.

Aged ; Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; methods ; Electrocardiography ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; surgery

PURPOSE: Atrial fibrillation (AF) is one of the major risk factors for ischemic stroke, and 90% of thromboembolisms in these patients arise from the left atrial appendage (LAA). Recently, it has been documented that an LAA occlusion device (OD) is not inferior to warfarin therapy, and that it reduces mortality and risk of stroke in patients with AF. MATERIALS AND METHODS: We implanted LAA-ODs in 5 Korean patients (all male, 59.8+/-7.3 years old) with long-standing persistent AF or permanent AF via a percutaneous trans-septal approach. RESULTS: 1) The major reasons for LAA-OD implantation were high risk of recurrent stroke (80%), labile international neutralizing ratio with hemorrhage (60%), and 3/5 (60%) patients had a past history of failed cardioversion for rhythm control. 2) The mean LA size was 51.3+/-5.0 mm and LAA size was 25.1x30.1 mm. We implanted the LAA-OD (28.8+/-3.4 mm device) successfully in all 5 patients with no complications. 3) After eight weeks of anticoagulation, all patients switched from warfarin to anti-platelet agent after confirmation of successful LAA occlusion by trans-esophageal echocardiography. CONCLUSION: We report on our early experience with LAA-OD deployment in patients with 1) persistent or permanent AF who cannot tolerate anticoagulation despite significant risk of ischemic stroke, or 2) recurrent stroke in patients who are unable to maintain sinus rhythm.
Aged ; Anticoagulants/contraindications ; Atrial Appendage/*physiopathology ; Atrial Fibrillation/epidemiology/*physiopathology/*surgery ; Humans ; Male ; Middle Aged ; Risk Factors ; *Septal Occluder Device ; Stroke/epidemiology/*prevention & control ; Treatment Outcome ; Warfarin/contraindications

Maze operation could alter P wave morphology in electrocardiogram (ECG), which might prevent exact diagnosis of the cardiac rhythm of patients. However, characteristics of P wave in patients with sinus rhythm after the operation have not been elucidated systematically. Consecutive patients who underwent the modified Cox Maze operation from January to December 2007 were enrolled. The standard 12-lead ECG and echocardiography were evaluated in patients who had sinus rhythm at 6 months after the operation. The average axis of P wave was 65+/-30 degrees. The average amplitude of P wave was less than 0.1 mV in all 12-leads, with highest amplitude in V1. The most common morphology of P wave was monophasic with positive polarity (49%), except aVR lead, which was different from those in patients with enlarged left atrium, characterized by large P-terminal force in the lead V1. There were no significant differences in P-wave characteristics and echocardiographic parameters between patients with LA activity (30.6%) versus without LA activity (69.4%) at 6 months after the operation. In conclusion, the morphology of P wave in patients after Maze operation shows loss of typical ECG pattern of P mitrale: P wave morphology is small in amplitude, monophasic and with positive polarity.
Atrial Fibrillation/*physiopathology/*surgery ; Cardiovascular Surgical Procedures/*methods ; Electrocardiography/*methods ; Female ; Heart Conduction System/*physiopathology/*surgery ; *Heart Rate ; Humans ; Male ; Middle Aged ; Treatment Outcome

BACKGROUNDLinear ablation of left atrium (LA) guided by three dimensional (3-D) electroanatomical mapping (Carto) has been used in many centres worldwide for the treatment of atrial fibrillation (AF) instead of pure anatomical approaches. There were little data about linear ablation of LA guided by Carto and double Lasso catheters in China. We report the results of linear ablation of LA guided by both Carto and double Lasso catheters.

METHODSAfter the anatomical model of LA and all pulmonary veins (PVs) had been established, circumferential ablations of the left pulmonary vein antrum and the right pulmonary vein antrum were performed with 2 circumferential mapping catheters (Lasso) placed within the ipsilateral superior and inferior PVs. The endpoint of ablation was abolishment or dissociation of the pulmonary vein potentials (PVPs). Oral amiodarone or propafenone was taken for at least 3 months by patients with persistent AF, permanent AF or those whose PVPs had not been isolated completely. The recurrence of atrial tachyarrhythmias was observed 3 months after the procedure.

RESULTSThere were 106 patients (mean age, 51.4 +/- 9.9 years). Seventy-eight patients had paroxysmal AF, 12 persistent AF and 16 permanent AF. Onset of atrial fibrillation occurred in 52 patients during ablation procedure. Thirty-two patients restored to sinus rhythm eventually after the procedure. Abolishment or dissociation of PVPs was accomplished during the procedure in 94 patients (88.7%). The duration of procedure and exposure to X-ray were (213 +/- 45) minutes and (32.5 +/- 12.8) minutes, respectively. Among the 87 patients followed up for over 3 months, 62 were free of atrial tachyarrhythmias (including 8 patients who were still taking oral amiodarone). The success rate was 71.3% in the first procedure. Two patients had pericardial effusion treated by pericardial puncture and effusion drainage. No pulmonary vein stenosis, atrioesophageal fistula, stroke or procedural death occurred.

CONCLUSIONSCombination of double Lasso catheters with 3-D electroanatomical mapping to guide the linear ablation of left atrium procedure can confirm the isolation of PVPs.

Adult ; Aged ; Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; methods ; Electrophysiologic Techniques, Cardiac ; methods ; Female ; Heart Atria ; surgery ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; physiopathology

BACKGROUNDPulmonary vein (PV) isolation has been developed to treat patients with atrial fibrillation (AF), and the electrophysiological endpoint of PV isolation is the disappearance or dissociation of pulmonary vein potentials (PVPs). Pulmonary vein tachycardia (PVT) is the dissociated PV rhythm with a rapid rate. However, the characteristics and significance of PVT after pulmonary vein isolation in patients with AF remains unclear.

METHODSFrom June 2003 to June 2005, a total of 285 consecutive patients with drug refractory AF were included in this study, and they underwent segmental pulmonary vein ablation (SPVA) or circumferential pulmonary vein ablation (CPVA). PV isolation was the initial endpoint for both approaches with documenting disappearance or dissociation of PVPs. PVT was characterized as dissociated activities within PVs with a circle length (CL) of < 300 ms, and was classified into organized PVT or disorganized PVT according to the variance of CL. Systematic follow-up was conducted after initial procedures. Continuous variables were analyzed by Student's t test and categorical variables were analyzed by chi-square test.

RESULTSThree hundred and fifteen PVs were ablated in 85 patients underwent SPVA approach, 400 circular lesions surrounding ipsilateral PVs (including 790 PVs) were produced in the rest of 200 patients received CPVA approach. Electrical isolation was achieved in all of these PVs. Of these, PVPs were abolished in 89.8% (992/1105) of the ablated PVs, dissociated PV rhythms were documented in the rest 10.2 % (113/1105) of the treated PVs. Among the 113 dissociated PV rhythms, 28 met the criteria of PVT with mean CL of (155 +/- 43) ms (2 PVTs in 2 patients received SPVA, 26 PVTs in 18 patients underwent CPVA). PVT was more frequently documented in patients underwent CPVA approach [9.0% (18/200) vs 2.3% (2/85), P = 0.04]. During the 6-month follow-up, it was indicated that no significant difference existed in AF free rate between patients with PVT and those without PVT (P = 0.75).

CONCLUSIONSPVT dissociated from LA activations can be documented after PV isolation, especially in patients underwent CPVA approach. However, PVT does not affect the follow-up results.

Adolescent ; Adult ; Aged ; Atrial Fibrillation ; physiopathology ; surgery ; Catheter Ablation ; adverse effects ; Female ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; physiopathology ; surgery ; Tachycardia ; etiology

PURPOSE: The Maze procedure has shown excellent efficacy in the elimination of atrial fibrillation (AF); however, little is known about the quality of functional recovery in the left atrium (LA) following successful sinus rhythm conversion by the Maze procedure. MATERIALS AND METHODS: We prospectively enrolled 12 patients (aged 52.5+/-10.1 years, 1 female) with valvular AF undergoing mitral valve surgery combined with the Maze procedure. Parameters of LA function in three anatomic compartments [anterior, posterior, and LA appendage (LAA)] were evaluated using electrocardiography-gated dual-source cardiac CT at one month and at six months after surgery. Twelve subjects matched by age, gender, and body surface area served as controls. RESULTS: At one month after surgery, ejection fraction (EF) and emptying volume (EV) of the LA were 14.9+/-7.4% and 21.3+/-9.7 mL, respectively, and they were significantly lower than those of the control group (EF, 47.9+/-11.2%; EV, 46.0+/-10.7%; p<0001). These values did not significantly change throughout late periods (p=0.22 and 0.21, respectively). Functional contributions of the anterior, posterior, and appendage compartments (EV of each compartment/overall EV) were 80.4%, -0.9%, and 20.5%, respectively, for those with LAA preservation (n=6); 100.1%, -0.1%, and 0% for those with LAA resection (n=6; p<0.05); and 62.2%, 28.2%, and 9.7% in the control subjects (p<0.001). CONCLUSION: Contractile functions of the LA significantly decreased after the Maze procedure. Functional contributions of three compartments of the LA were also altered. The influence of LAA preservation on postoperative LA functions needs to be evaluated through studies of larger populations.
*Ablation Techniques ; Adult ; Aged ; Atrial Appendage/*physiopathology ; Atrial Fibrillation/physiopathology/*surgery ; Atrial Function, Left/*physiology ; Case-Control Studies ; Electrocardiography/methods ; Female ; Heart Atria ; Humans ; Male ; Middle Aged ; Prospective Studies ; Recovery of Function ; Tomography, X-Ray Computed

OBJECTIVETo compare the efficacy and safety of segmental pulmonary vein isolation (SPVI) and circumferential pulmonary vein isolation (CPVI) guided by EnSite NavX system in patients with atrial fibrillation (AF).

METHODSEighty-five patients with paroxysmal AF and persistent AF were enrolled in this study. Forty patients (30 with paroxysmal AF and 10 with persistent AF) underwent SPVI procedure, and 45 (31 with paroxysmal AF and 14 with persistent AF) underwent CPVA guided by EnSite NavX three-dimensional electrophysiological mapping system. All the patients were followed up for over six months.

RESULTSThe success rate was 65% in the SPVI group and 84.4% in the CPVI group (P=0.0332), with incidence of major complications of 17.5% and 6.7%, respectively (P=0.0845). In the SPVI group, 12.5% patients had pulmonary vein stenosis after the operation, which occurred in none of the patients in the CPVI group (P=0.0312). The total procedure time was 200.4+/-37.0 min in the SPVI group, significantly shorter than that in the CPVI group (226.5+/-26.1 min, P=0.002). The fluoroscopy time in the SPVI group was obviously longer than that in the CPVI group (54.7+/-9.7 vs 27.1+/-3.1 min, P<0.001).

CONCLUSIONSCPVI guided by EnSite NavX system is more effective than SPVI for treatment of atrial fibrillation with significantly shortened fluoroscopy time but prolonged procedure time. The two procedures results in comparable incidences of major complications, but CPVI is associated with reduced rate of pulmonary vein stenosis in comparison with SPVI.

Aged ; Atrial Fibrillation ; surgery ; Catheter Ablation ; adverse effects ; methods ; Electrophysiologic Techniques, Cardiac ; methods ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Pulmonary Veins ; physiopathology ; surgery

BACKGROUNDBased on the hypothesis that pulmonary vein isolation could result in the damage of the epicardial fat pads, this study aimed to investigated the impact of right upper pulmonary vein (RUPV) isolation on vagal innervation to atria.

METHODSBilateral cervical sympathovagal trunks were decentralized in 6 dogs. Metoprolol was given to block sympathetic effects. Multipolar catheters were placed into the right atrium (RA) and coronary sinus (CS). RUPV isolation was performed via transseptal procedure. Atrial effective refractory period (ERP), vulnerability window (VW) of atrial fibrillation (AF), and sinus rhythm cycle length (SCL) were measured at RA and distal coronary sinus (CSd) at baseline and vagal stimulation before and after RUPV isolation. Serial sections of underlying tissues before and after ablation were stained with haematoxylin and eosin.

RESULTSSCL decreased significantly during vagal stimulation before RUPV isolation (197 +/- 21 vs 13 +/- 32 beats per minute, P < 0.001), but remained unchanged after RUPV isolation (162 +/- 29 vs 140 +/- 39 beats per minute, P > 0.05). ERP increased significantly before RUPV isolation compared with that during vagal stimulation [(85.00 +/- 24.29) ms vs (21.67 +/- 9.83) ms at RA, P < 0.001; (90.00 +/- 15.49) ms vs (33.33 +/- 25.03) ms at CSd P < 0.005], but ERP at baseline hardly changed after RUPV isolation compared with that during vagal stimulation [(103.33 +/- 22.50) vs (95.00 +/- 16.43) ms at RA, P = 0.09; (98.33 +/- 24.83) vs (75.00 +/- 29.50) ms at CSd, P = 0.009]. The ERP shortening during vagal stimulation after RUPV isolation decreased significantly [(63.33 +/- 22.51) ms vs (8.33 +/- 9.83) ms at RA, P < 0.005; (56.67 +/- 20.66) ms vs (23.33 +/- 13.66) ms at CSd, P < 0.05]. AF was rarely induced at baseline before and after RUPV isolation (VW close to 0), while VW of AF to vagal stimulation significantly decreased after RUPV isolation [(40.00 +/- 10.95) vs 0 ms at RA, P < 0.001; (45.00 +/- 32.09) vs (15.00 +/- 23.45) ms at CS, P < 0.05]. The architecture of individual ganglia was significantly altered after ablation.

CONCLUSIONSThe less ERP shortening to vagal stimulation and altered architecture of individual ganglia after right upper pulmonary vein isolation indicate that isolation may result in damage of the epicardial fat pads, thereby attenuating the vagal innervation to atria. The decreased vulnerability window of atrial fibrillation indicates that vagal denervation may contribute to its suppression.

Animals ; Atrial Fibrillation ; etiology ; physiopathology ; surgery ; Dogs ; Female ; Ganglia ; pathology ; Heart Atria ; innervation ; Male ; Pulmonary Veins ; surgery ; Refractory Period, Electrophysiological ; Vagus Nerve ; physiology