刘絮
阜外华中心血管病医院 手术部
INTRODUCTION:The "Crosstalk" technique: if pulmonary vein isolation (PVI) of the superior one is not achieved due to a gap in the inferior part, it could be done during inferior vein cryoablation. This maneuver minimizes the total energy delivery time and number of lesions. We aimed to correlate the likelihood of crosstalk phenomenon with certain anatomic characteristics.METHODS:A total of 676 patients undergoing a first ablation procedure for paroxysmal or persistent atrial fibrillation (470 first-generation cryoballoon [CB] and 206 second-generation CB) between June 2014 and December 2016 were included.RESULTS:"Crosstalk" phenomenon occurred in 32 patients (18 first-generation CB, 14 second-generation CB). Compared to 54 control patients without crosstalk, the angle between left superior pulmonary vein (LSPV) and left atrial (LA) roof-plane, left pulmonary common ostia were significant parameters associated with crosstalk (odds ratio [OR] = 1.20, ±95% confidence interval [CI]: 1.11-1.31, P < 0.001; OR = 5.67, ±95% CI: 1.08-28.69, P = 0.04). As for angle between LSPV and LA roof-plane, the cut-off value was 28.68° with a sensitivity of 72.22%, a specificity of 81.25%, and an area under the receiver operating characteristic curve of 0.87 to predict the possibility of crosstalk technique application to get isolated in LSPV. Among the crosstalk group, there was no statistical difference between first-generation CB and second-generation CB in pulmonary anatomic characteristics.CONCLUSION:Crosstalk technique can be effective in patients with AF undergoing CB ablation using with both first and second-generation CBs. Anatomic characteristics predictive of crosstalk include a left common ostia and smaller angle between the LSPV and LA roof-plane.
Pacing and clinical electrophysiology : PACE 2018
Aims:We aimed to examine the electrocardiographic and electrophysiologic characteristics of anterograde-conducting decremental accessory pathways (DAP) and to identify surrogate criteria to distinguish short atrioventricular (SAV) DAP from atriofascicular (AF) AP and long atrioventricular (LAV) DAP.Methods and results:We identified all patients with DAPs and analysed electrocardiographic and electrophysiologic characteristics. Distal insertion sites were examined using existing criteria, including V-H interval, ventricular activation at the right ventricular apex, and around tricuspid annulus during antidromic atrioventricular re-entrant tachycardia (A-AVRT) or complete pre-excitation and evaluated the AV node-like properties according to the response to adenosine and radiofrequency ablation. Out of 45 patients with DAPs, 28 (62.2%) had SAV-DAP (13 with definite AF-AP, 2 with definite LAV-DAP, 2 indeterminate). In all, 50% of SAV-DAPs and 53.3% of AF-AP/LAV-DAPs had 'rS' pattern in lead III. Longer QRS duration (159.9 ± 17.4 ms vs. 139.2 ± 14.3 ms, P < 0.0001) during full pre-excitation or A-AVRT differentiated SAV-DAP from AF-AP. The QRS-V(His) interval was longer for those with SAV-DAP compared vs. AF-AP/LAV-DAP (45.3 ± 2.4 ms vs. 22.9 ± 2.5 ms, P < 0.0001) and a cut-off value of 33.0 ms differentiated the two (sensitivity 81.3%, specificity 87.5%).Conclusion:The majority of the SAV-DAPs are located at the TA free wall. An 'rS' pattern in lead III is frequently seen in SAV-DAP as well as AF-AP/LAV-DAPs. Measuring the QRS-V(His) interval would be helpful to distinguish SAV-DAP from AF-AP/LAV-DAP.
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2018
BACKGROUND:Right atrial (RA) dual-loop reentrant tachycardia has been described in patients who have undergone open heart surgery. However, the prevalence, electrophysiological (EP) substrate, and ablation outcomes have been poorly characterized.OBJECTIVE:The purpose of this study was to investigate the prevalence, EP substrate, and ablation outcomes for RA dual-loop reentrant tachycardia after cardiac surgery.METHODS:We identified all patients with atrial tachycardia (AT) after cardiac surgery. We compared EP findings and outcomes of those with RA dual-loop reentrant tachycardia to a control group of patients with RA macroreentrant arrhythmias in the setting of linear RA free-wall (FW) scar.RESULTS:Of the 127 patients with 152 postsurgical ATs, 28 of the ATs (18.4%) had RA dual-loop reentry and 24 of 28 (85.7%) had tricuspid annular reentry combined with FW incisional reentry. An incision length >51.5 mm along the FW predicted the substrate for a second loop. In 22 of 23 patients (95.7%) with initial ablation in the cavotricuspid isthmus, a change in the interval between Halod to CSp could be recorded, and 15 of 23 patients (65.2%) had coronary sinus activation pattern change. Complete success was achieved in 25 of 28 patients (89.3%) in the dual-loop reentry group and in 64 of 69 patients (92.8%) in the control group. After mean follow-up of 33.9 ± 24.2 months, 24 of 28 patients (85.7%) and 60 of 69 patients (86.95%) were free of arrhythmias after the initial procedure in the 2 groups, respectively.CONCLUSION:The prevalence of RA dual-loop reentry is 18.4% of ATs with prior atriotomy scar. A long incision should alert physicians to the possibility of a second loop at the FW. Halo and coronary sinus activation patterns provide important clues to circuit transformation.
Heart rhythm 2018
Aims:We sought to investigate the clinical, electrocardiographic, and electrophysiological characteristics of left upper septal fascicular ventricular tachycardia (LUS-VT).Methods and results:Eleven consecutive patients with LUS-VT were identified among 196 patients with left fascicular ventricular tachycardia (VT). Clinical VTs presented as paroxysmal in 8 patients and incessant in 3 patients. Six patients had previous left posterior fascicular VT ablation history. All VTs had narrow QRS complexes with QRS duration of 101.1 ± 9.2 ms. The frontal QRS axis was normal or right deviation. Precordial morphology was either right bundle branch block type or similar to that of sinus rhythm. A retrograde His with H-V interval of 21.9 ± 7.2 ms was recorded during VT. The earliest Purkinje potential (PP) to QRS interval during VT averaged 35.7 ± 4.5 ms. Clear diastolic potentials (DPs) with high frequency and low amplitude were found in only one patient. Ten patients were managed successfully by 11 ablation sessions, and 1 patient declined ablation. Successful targets at the left upper septum were sites with the earliest PP (9 cases) or with DP (1 case) during VT. After ablation, 2 cases (10%) developed new left anterior hemiblock or incomplete left bundle branch block. No VT recurred during a median follow-up period of 3.2 (range 1.0-12.7) years.Conclusion:LUS-VT presented as narrow QRS complex tachycardia. Some LUS-VTs occurred after ablation targeting left posterior fascicular VT. The VTs can be managed successfully by focal ablation at the left upper septum with a mild risk of fascicular injury.
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2018
OBJECTIVE:The study sought to evaluate the procedural and biophysical factors related to acute pulmonary vein isolation (PVI) guided by real-time pulmonary vein (PV) potential recordings.METHODS:A total of 180 consecutive patients with drug-resistant atrial fibrillation (AF) undergoing CB2 (second-generation version of cryoballoon) ablation were enrolled. Real-time monitoring of PV potentials was obtained using an inner lumen spiral mapping catheter.RESULTS:Acute isolation was achieved in all PVs without touch-up ablation. Real-time assessment of PV disconnection was possible in 611 of 711 (85.9%) PVs. A total of 617 (86.8%) PVs were isolated during the initial freeze. Longer time cycle integration (TCI) (TTI * freeze cycle, TCI) (254.6 ± 112.8 seconds vs 74.1 ± 59.7 seconds, P < 0.001), time to isolation (TTI) (94.3 ± 34.0 seconds vs 46.3 ± 26.2 seconds, P < 0.001), higher nadir temperature (-45.5 ± 5.3°C vs -50.4 ± 5.5°C, P < 0.001), longer time to -40°C (77.3 ± 22.7 seconds vs 55.7 ± 23.2 seconds, P < 0.001), faster interval rewarming time at 0°C (9.4 ± 4.3 seconds vs 12.4 ± 4.9 seconds, P = 0.008), and total balloon rewarming time (38.1 ± 11.6 seconds vs 47.7 ± 14.0 seconds, P = 0.003) were observed in PVs with acute reconduction. TTI ≤ 65 seconds predicted absence of acute reconnection with 84.2% sensitivity and 75.7% specificity, whereas TCI ≤ 119 seconds presented 94.7% sensitivity and 80.2% specificity. At a mean follow-up of 4.7 ± 1.4 months, 82.2% of patients were free of AF. None of those with PV reconnections suffered from AF recurrences.CONCLUSIONS:The ablation using CB2 is effective in achieving acute PVI. Real-time assessment of PVI could be achieved during CB application in 86% of PVs. The incidence of spontaneous PV reconnection is very low, observed in just 3% of isolated PVs. TTI ≤ 65 seconds and TCI ≤ 119 seconds predicted absence of acute PV reconnection. Although they may identify effective cryoapplications in the acute phase, their performance still needs to be verified in the long term.
Pacing and clinical electrophysiology : PACE 2018
OBJECTIVE:To evaluate the performance of the non-laboratory INTERHEART risk score (NL-IHRS) to predict incident cardiovascular disease (CVD) across seven major geographic regions of the world. The secondary objective was to evaluate the performance of the fasting cholesterol-based IHRS (FC-IHRS).METHODS:Using measures of discrimination and calibration, we tested the performance of the NL-IHRS (n=100 475) and FC-IHRS (n=107 863) for predicting incident CVD in a community-based, prospective study across seven geographic regions: South Asia, China, Southeast Asia, Middle East, Europe/North America, South America and Africa. CVD was defined as the composite of cardiovascular death, myocardial infarction, stroke, heart failure or coronary revascularisation.RESULTS:Mean age of the study population was 50.53 (SD 9.79) years and mean follow-up was 4.89 (SD 2.24) years. The NL-IHRS had moderate to good discrimination for incident CVD across geographic regions (concordance statistic (C-statistic) ranging from 0.64 to 0.74), although recalibration was necessary in all regions, which improved its performance in the overall cohort (increase in C-statistic from 0.69 to 0.72, p<0.001). Regional recalibration was also necessary for the FC-IHRS, which also improved its overall discrimination (increase in C-statistic from 0.71 to 0.74, p<0.001). In 85 078 participants with complete data for both scores, discrimination was only modestly better with the FC-IHRS compared with the NL-IHRS (0.74 vs 0.73, p<0.001).CONCLUSIONS:External validations of the NL-IHRS and FC-IHRS suggest that regionally recalibrated versions of both can be useful for estimating CVD risk across a diverse range of community-based populations. CVD prediction using a non-laboratory score can provide similar accuracy to laboratory-based methods.
Heart (British Cardiac Society) 2018
We aim to evaluate the association of systolic and diastolic blood pressure (SBP and DBP) with estimated urinary sodium (Na) and potassium(K) excretions, and their gram-to-gram Na/K ratio across various salt-diet regions during 2005-2009 in China. A prospective cohort study was conducted to recruit 46,285 participants in China. A single fasting morning urine specimen was collected to estimate 24-hour urinary Na and K excretion using Kawasaki formula. Means of estimated Na and K were 5.7 ± 1.7 and 2.1 ± 0.5 grams/day, respectively, and mean estimated Na/K ratio was 2.8 ± 0.8. Adjusted analyses showed 1.70 mmHg SBP and 0.49 mmHg DBP increase per 1-g increment of estimated Na, while 1.10 mmHg SBP and 0.91 mmHg DBP decrease for one-gram increase of K. A significant increase in SBP (4.33 mmHg) and DBP (1.54 mmHg) per 1 unit increase in Na/K ratio was observed. More changes of SBP (4.39 mmHg) and DBP (1.67 mmHg) per one-unit increase of Na/K ratio were observed in low-salt regions, though significant changes were also found in moderate- and heavy-salt regions (P for heterogeneity < 0.01). Conclusively, decreasing sodium combined with increasing potassium is likely to have a more beneficial effect than decreasing sodium alone, even if those were living in low-salt regions.
Scientific reports 2018
BACKGROUND:Focal atrial tachycardias (ATs) from the parahisian region can be successfully ablated from the right atrial septum (RAS), noncoronary cusp (NCC), and right middle septum (RMS). The optimal mapping and ablation strategy for ATs from these sites remains unclear.OBJECTIVE:The purpose of this study was to investigate the electrophysiologic characteristics and optimal ablation sites of parahisian ATs from the RAS, RMS, and NCC.METHODS:A total of 362 patients with ATs undergoing radiofrequency catheter ablation of ATs were included. A detailed examination including ECG analysis and electrophysiologic study was performed.RESULTS:Overall, 91 patients had a parahisian site of AT origin, and ablation was successful in 86 (94.5%). ATs were successfully eliminated from the RAS in 23, RMS in 19, and NCC in 44. The earliest "A" potential was recorded at the distal His catheter in 69.4% of NCC ATs vs the proximal His catheter in 83.3% of RAS ATs and 86.7% of RMS ATs. Mean timing of the "A" potential of RMS ATs recorded at the His-bundle catheter was -18.25 ± 7.20 ms, which was later than ATs from the RAS (-24.59 ± 8.73 ms) or NCC (-27.08 ± 5.63 ms). For ATs originating from the RAS and RMS, an A/V ratio <1.22 predicted safe and successful ablation (sensitivity 88.4%, specificity 91.7%).CONCLUSION:For parahisian ATs, activation sequence and timing of the "A" on the His catheter can provide clues for the origin of ATs. When ablating at the RAS and RMS, an A/V ratio >1.22 identified safe and effective ablation sites.
Heart rhythm 2017
OBJECTIVE:The present study aimed to retrospectively investigate long-term clinical outcomes of patients undergoing catheter ablation of left posterior fascicular ventricular tachycardia (LPF-VT) with the development of left posterior fascicular block (LPF block) and characteristics of repeat procedures.METHODS AND RESULTS:A total of 195 patients (mean age 29.76±1.03years, 16.4% females) who underwent catheter ablation for LPF-VT were consecutively enrolled. The earliest ventricular potential with a single fused Purkinje potential (PP) during VT and the PP located in the inferior-apical or mid-apical septum during SR were targeted for linear ablation. The endpoint of the procedure was noninducible VT and development of new-onset LPF block. Follow-up with clinic visits or telephonic interviews, electrocardiogram (ECG), or Holter monitoring was performed after the procedure. With a median follow-up of 85 (18,181) months, 20 patients were censored and 152 of 175 (86.86%) patients had long-term freedom from VT after a single procedure. No statistical difference in the outcome of catheter ablation of LPF-VT was found between inducible and non-inducible groups (P=0.89). Twenty-three patients exhibited recurrent LPF-VT. Seven of 23 patients developed new-onset left upper septal ventricular tachycardia that was successfully ablated. All the patients undergoing repeat procedures had freedom from VT. No procedural complications occurred.CONCLUSIONS:Ablation of LPF-VT using the development of LPF block as the endpoint is associated with a high procedural success rate. No difference in freedom from LPF-VT was found between inducible and non-inducible patients. New-onset LPF block recovery and non-early PP-QRS interval can be the predictors of LPF-VT repeat procedure.
International journal of cardiology 2017
AIMS:We sought to investigate focal atrial tachycardias (ATs) in patients with congenitally corrected transposition of the great arteries (ccTGA).METHODS AND RESULTS:We identified three cases of focal ATs with ccTGA from 2007 to 2015. The clinical findings, electrocardiography, electrophysiological features, and ablation were reported. All three cases had {S,L,L}-type ccTGA. The AT P waves shared the following features: narrow in width, positive in leads I and aVL, and negative/positive in lead V1. All ATs had focal activation pattern with early activation at the anteroseptal area, and further mapping demonstrated earliest atrial activation (EAA) inside the pulmonary sinus cusps (PSCs), especially the right PSC. In Cases 1 and 2, double potentials were recorded at the EAA sites. Conduction delay between the two potentials during atrial extrastimulus was observed. After successful ablation, the second potential during sinus rhythm was further delayed in Case 1 and was eliminated in Case 2. However, only one potential was recorded in Case 3. All three cases were successfully managed by ablating the sites with EAA, which preceded the P-wave onset by 60, 80, and 42 ms, respectively. During ablation, no junctional rhythm was observed. Incomplete left bundle branch block was induced during mapping in Case 1, but no other complications occurred. All patients were free from tachycardia during follow-up periods of 36, 7, and 5 months, respectively.CONCLUSION:Anteroseptal AT in patients with ccTGA could be eliminated by ablation inside the PSC.
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology 2017
