Maurits Wijffels - Academia.edu (original) (raw)

Papers by Maurits Wijffels

Netherlands Heart Journal, 2021

Introduction The AcQMap High Resolution Imaging and Mapping System was recently introduced. This ... more Introduction The AcQMap High Resolution Imaging and Mapping System was recently introduced. This system provides 3D maps of electrical activation across an ultrasound-acquired atrial surface. Methods We evaluated the feasibility and the acute and short-term efficacy and safety of this novel system for ablation of persistent atrial fibrillation (AF) and atypical atrial flutter. Results A total of 21 consecutive patients (age (mean ± standard deviation) 62 ± 8 years, 23% female) underwent catheter ablation with the use of the AcQMap System. Fourteen patients (67%) were treated for persistent AF and 7 patients (33%) for atypical atrial flutter. Eighteen patients (86%) had undergone at least one prior ablation procedure. Acute success, defined as sinus rhythm without the ability to provoke the clinical arrhythmia, was achieved in 17 patients (81%). At 12 months, 4 patients treated for persistent AF (29%) and 4 patients treated for atypical flutter (57%) remained in sinus rhythm. Complic...

doi:10.1093/europace/eup221

Alaaddin Yilmaz, Mercedes Nadal, Elena Sandoval, Naiara Calvo, Josep Brugada, Lucas V.A. Boersma,... more Alaaddin Yilmaz, Mercedes Nadal, Elena Sandoval, Naiara Calvo, Josep Brugada, Lucas V.A. Boersma, Manuel Castella, WimJan van Boven, Antonio Berruezo, (FAST) : A 2-Center Randomized Clinical Trial Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment ISSN: 1524-4539 Copyright © 2011 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX published online November 14, 2011 Circulation http://circ.ahajournals.org/content/early/2011/11/13/CIRCULATIONAHA.111.074047 located on the World Wide Web at: The online version of this article, along with updated information and services, is

European Heart Journal, 2018

Atrial fibrillation ablation Methods: A total of 5011 patients with AF ablation were followed for... more Atrial fibrillation ablation Methods: A total of 5011 patients with AF ablation were followed for three years in Kansai Plus Atrial Fibrillation (KPAF) Registry. 4944 patients were not on HD (HD-group, 99%), and 67 patients were on HD (HD+ group, 1%). Sinus rhythm (SR) maintenance rate in HD-group and HD+ group was assessed with Kaplan-Meier method. Results: In HD-group, 2092 patients (42%) had ERs, and in HD+ group, 35 patients (52%) had ERs. There was no significant difference in the occurrence of ERs between two groups (p=0.10). In the patients with ERs, SR maintenance rate at three years after initial AF ablation in HD+ group (n=35) was significantly lower than in HD-group (n=2092) (11.4%, 35.5% respectively, log-rank p=0.005, see figure left). However, in the patients without ERs, there was no significant difference between two groups (log-rank p=0.62, see figure right). Figure 1 Conclusions: In HD patients, ER was a high risk of LR. However, if there was no ER, a good outcome was shown, as in the case without HD. P1911 The impact of manual vs remote magnetic navigation in the very long-term outcomes of catheter ablation of atrial fibrillation: a propensity score analysis

EP Europace, 2018

Left atrial appendage closure (LAAC) is increasingly used as an alternative to oral anticoagulati... more Left atrial appendage closure (LAAC) is increasingly used as an alternative to oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) patients. Feasibility and safety of left atrial (LA) catheter ablation (CA) in patients with previously implanted LAAC devices have not been well studied. We report on the feasibility, safety, and efficacy of LA CA in the presence of a previously implanted LAAC device.

EP Europace, 2016

Adenosine may unmask dormant pulmonary vein (PV) conduction after PVI. Its clinical impact remain... more Adenosine may unmask dormant pulmonary vein (PV) conduction after PVI. Its clinical impact remains controversial. This is the first study assessing adenosine challenge during PVI with the improved PVAC GOLD catheter, taking into account the recurrence of AF, localisation of dormant PV conduction and its relation with reconnection sites seen in repeated PVI during follow up. Methods: In this study, patients with symptomatic paroxysmal AF were included. After ostial PVI using PVAC GOLD catheter, adenosine (12 mg) was administered for each PV 20min after isolation. Presence and sites of dormant PV were noted. No additional ablation was performed. Results: A number of 172 patients were included (table). A total of 673 PV's were targeted. Ninety-seven (97) PV's in 71 patients (41%) showed dormant PV conduction. Common sites of reconnection were the left-sided carina (48%); 37% in the inferior site of the superior PV and 11% in the superior site of the inferior PV. Patients with dormant PV conduction showed in 26.8% recurrence of AF vs 16.8% without reconnection. In both groups 7 patients underwent repeated PVI. Reconduction sites corresponded with the localisation of the adenosine-provoked dormant PV conduction in 5 of 7 patients (71%); 6/7 patients also showed reconnection on other sites. Conclusion: Our study shows that patients with adenosine-provoked dormant PV conduction during PVI with PVAC GOLD catheter are more prone to recurrent AF. The sites of dormant conduction seem to be good predictors of the number and site of reconnected PV's needed to be ablated during repeated PVI due to recurrent AF. Table. Patient and procedural characteristics.

EP Europace, 2016

Purpose: cardiac resynchronization therapy (CRT) still has a significant non-response rate of 30%... more Purpose: cardiac resynchronization therapy (CRT) still has a significant non-response rate of 30%. In patients with atrial fibrillation (AF) the rate of non-responders is even higher, and few studies focused on this specific subgroup of patients. Triple-site pacing (Tri-V) is a new method of CRT which may help overcome these limitations. We aim to assess the effectiveness of this new type of CRT in patients with permanent AF. Methods: single-center prospective observational study of patients with permanent AF, NYHA class ! II and ejection fraction , 35% who underwent CRT implantion. 2 leads were implanted in the right ventricle, one in the apex and another in the outflow tract septal wall. A left ventricle lead was implanted as usual in a conventional CRT. Within 1 month after implantation, all patients underwent minimally invasive hemodynamic assessment using the Vigileo Flotracw (Edwards Lifesciences) for the determination of cardiac output in Tri-V or conventional biventricular pacing (Bi-V). The final mode (Tri-V vs Bi-V) was programmed according to the hemodynamic performance. Patients follow-up (FUP) was then undertaken at 6 and 12 months, and included clinical assessment with NYHA class determination, quality of life (Qol) assessment with the Minesota QoL questionaire, 6-minute walk test (6MWT) and echocardiogram with determination of the ejection fraction (EF). Patients were classified as responders if NYHA class was reduced by at least one level and EF increase of ! 10%, and as super-responders if NYHA class at FUP was I and EF ! 50%. Survival rates and survival free of heart failure hospitalization were calculated. For statistical analysis we used the paired samples T test. Summary of Results: we included 40 patients (93% male, mean age 72 + 10 years). 32 (80%) were programmed in Tri-V based on the hemodynamic test results. The following results pertain to this subgroup. At baseline, 58% of pts were in NYHA class III and 42% NYHA class II, with a mean ejection fraction of 28% + 5. After completion of 1 year of follow-up, mean QoL score more than halved (31 + 21 vs. 15 + 18; p ¼ 0,017 at 12 months), the 6MWT distance was significantly improved in the responder group (416 + 104 m to 465 + 107 m, p ¼ 0,005 at 12 months) and the mean ejection fraction also increased (28 + 5 vs. 40 + 10; p , 0,001 at 6 months and 28 + 5 vs. 41 + 10; p , 0,001 at 12 months). The responder rate was 62% at 6 months and 76% at 12 months. The super-responder rate was 9% at 6 months and 25% at 12 months. 4 pts died. Survival free of of heart failure hospitalization was 87,5%. Conclusion: Tri-V CRT yielded a high response rate, and a much higher super-response rate, than usually reported for conventional CRT in patients with permanent AF. There was a clear improvement in functional capacity and QoL, as well as positive reverse remodeling. These results may warrant considering Tri-V as a first line therapy in patients with permanent AF who are candidates for CRT, or as an upgrade option in non-responders.

Journal of cardiovascular electrophysiology, Jan 4, 2017

Optimal left ventricular (LV) lead position in patients undergoing cardiac resynchronization ther... more Optimal left ventricular (LV) lead position in patients undergoing cardiac resynchronization therapy(CRT) is crucial to achieve an optimal effect on hemodynamics. Due to various difficulties, up to 30% of transvenous LV lead placements fail, or a suboptimal position is achieved. Surgical epicardial LV lead placement could be performed at a position anticipated to be the optimal site. This could have a more favorable effect, which may be expressed by increased improvement in left ventricular ejection fraction(LVEF) and cardiac perfusion. The objective of this trial is to compare transvenous versus epicardial LV lead placement in CRT in a randomized fashion METHODS AND RESULTS: : 52 patients were randomized to either epicardial or transvenous approach. All patients received an ICD with CRT. Patients were followed for 6 months after device implant. Primary endpoint was the degree of change in cardiac perfusion measured by myocardial perfusion scintigraphy. LVEF equally improved in both...

Europace, 2016

A long-detection interval (LDI) (30/40 intervals) has been proved to be superior to a standard-de... more A long-detection interval (LDI) (30/40 intervals) has been proved to be superior to a standard-detection interval (SDI) (18/24 intervals) in terms of reducing unnecessary implantable cardioverter defibrillator (ICD) therapies. To better evaluate the different impact of LDI and anti-tachycardia pacing (ATP) on reducing painful shocks, we assessed all treated episodes in the ADVANCE III trial. Methods and results A total of 452 fast (200 ms , cycle length ≤ 320 ms) arrhythmic episodes were recorded: 284 in 138 patients in the SDI arm and 168 in 82 patients in the LDI arm (106/452 inappropriate detections). A total of 346 fast ventricular tachycardias (FVT) were detected in 169 patients: 208 in 105 patients with SDI and 138 in 64 patients with LDI. Setting LDI determined a significant reduction in appropriate but unnecessary therapies [208 in SDI vs. 138 in LDI; incidence rate ratio (IRR): 0.61 (95% CI 0.45-0.83), P ¼ 0.002]. Anti-tachycardia pacing determined another 52% reduction in unnecessary shocks [208 in SDI with hypothetical shock-only programming vs. 66 in LDI with ATP; IRR: 0.37 (95% CI 0.25-0.53, P , 0.001)]. The efficacy of ATP in terminating FVT was 63% in SDI and 52% in LDI (P ¼ 0.022). No difference in the safety profile (acceleration/degeneration and death/cardiovascular hospitalizations) was observed between the two groups. Conclusion The combination of LDI and ATP during charging is extremely effective and significantly reduces appropriate but unnecessary therapies. The use of LDI alone yielded a 39% reduction in appropriate but unnecessary therapies; ATP on top of LDI determined another 52% reduction in unnecessary shocks. The strategy of associating ATP and LDI could be considered in the majority of ICD recipients.

Circulation: Arrhythmia and Electrophysiology, 2016

Background— Single-shot ablation techniques may facilitate safe and simple pulmonary vein isolati... more Background— Single-shot ablation techniques may facilitate safe and simple pulmonary vein isolation to treat paroxysmal atrial fibrillation. Multielectrode pulmonary vein isolation versus single tip wide area catheter ablation-paroxysmal atrial fibrillation is the first multinational, multicenter, prospective, noninferiority randomized clinical trial comparing multielectrode-phased radiofrequency ablation (MEA) to standard focal irrigated radiofrequency ablation (STA) using 3-dimensional navigation. Methods and Results— Patients with paroxysmal atrial fibrillation were randomized to MEA (61 patients) or STA (59 patients). Preprocedure transesophageal echocardiogram and computed tomography/magnetic resonance imaging (also 6-month postprocedure) were performed. Mean age was 57 years, 25% female sex, BMI was 28, CHA 2 DS 2 –VASc score was 0 to 1 in 82%, 8% had previous right atrial ablation, whereas all had at least 1 antiarrhythmic drug failure. The MEA group had significantly shorter...

Monophasic Action Potentials, 1997

It has long been known that atrial fibrillation (AF) is a progressive disease. While it may first... more It has long been known that atrial fibrillation (AF) is a progressive disease. While it may first reveal itself in the form of shorter or longer paroxysms of AF, in many cases after some time atrial fibrillation no longer terminates spontaneously and the arrhythmia becomes persistent. Finally, as an endstage, atrial fibrillation can no longer be deflbrillated, or the arrhythmia recurs almost immediately after defibrillation (permanent AF). Mauricio Rosenbaum has coined the term “domestication of atrial fibrillation” to describe the clinical observation that instead of remaining a sinus rhythm, at a certain given moment AF becomes the predominant rhythm. There is little doubt that the natural history of AF, to a large extent is due to the progression of pathological anatomical changes in the atria either due to age (fibrosis, fatty degeneration), or an underlying heart disease (mitral valve disease, hypertension, coronary atherosclerosis). On the other hand the possibility should be considered that, irrespective of the progression of an underlying heart disease, atrial fibrillation per se might cause progressive changes to either the structure or the electrophysiological properties of the atria (electrical remodeling).

Journal of Interventional Cardiac Electrophysiology, 2013

The pulmonary vein ablation catheter (PVAC) is designed for pulmonary vein isolation (PVI). Elect... more The pulmonary vein ablation catheter (PVAC) is designed for pulmonary vein isolation (PVI). Electrical reconnection of pulmonary veins is believed to result in AF recurrence. The purpose of this study was to establish the location and extent of PV reconnection after PVI with the PVAC catheter. Eighty-two patients (79 % male, age 60 ± 9 years) that underwent a redo procedure for recurrent AF after PVAC ablation were assessed for prevalence and location of reconnection. The number of reconnected PV's was 0, 1, 2, 3, or 4 in 2 (2.4 %), 14 (17 %), 23 (28 %), 28 (34 %), and 15 (18 %) patients, respectively. Reconnection of left superior, left inferior, left common, right superior, and right inferior PV's was found in 66, 63, 83, 57, and 67 %, respectively (p = 0.48). In the left PV's, reconnection was located significantly more anterior than posterior; LSPV anterior 32/70 vs posterior 13/70 (p < 0.01), LIPV anterior 26/70 vs posterior 9/70 (p < 0.01). In the right PV's reconnection was distributed equally in all quadrants. Different modes of RF delivery during PVAC ablation (bipolar/unipolar 2:1 [n = 35] vs. 4:1 [n = 47]) yielded comparable rates of PV reconnection. During follow-up (median 296 days) no AF/AT was documented in 57 patients (70 %). Almost all patients (98 %) with AF after PVAC ablation show reconnection of at least one PV. All PV's are equally likely to show reconnection. In the left PV's, reconnection was found more often anteriorly than posteriorly. During pulmonary vein isolation with the PVAC catheter, prevalent sites of reconnection deserve close attention to increase success.

Journal of Cardiovascular Electrophysiology, 2009

ADVANCE III Trial. Introduction: The purpose of this investigation is to evaluate whether a prolo... more ADVANCE III Trial. Introduction: The purpose of this investigation is to evaluate whether a prolonged detection interval for life threatening ventricular tachyarrhythmia (VT) is able to reduce therapies (Rx) delivered by an implantable cardioverter/defibrillator (ICD). Until now, only the PREPARE trial demonstrated a reduction of ICD Rx in a cohort of primary prevention patients. Methods and Results: The ADVANCE III study is a prospective, randomized, parallel trial with 2 arms evaluating different intervals to detect (NID), i.e., 18/24 (as currently used) versus 30/40. The primary endpoint is to demonstrate a 20% reduction of ICD Rx (antitachycardia pacing or shocks) delivered to terminate spontaneous VT with a cycle length ≤320 ms in patients with Class I-IIA indication for ICD therapy, regardless of cardiac resynchronization capabilities. The worldwide investigation started in spring 2008 and is expected to be finished in 2011. Conclusions: The ADVANCE III trial is the first randomized investigation evaluating the reduction of ICD Rx for fast VT due to a prolongation of NID in a general ICD patient cohort.

Journal of Cardiovascular Electrophysiology, 2006

Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is based on a set... more Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is based on a set of criteria proposed by the International Task Force (TF) for Cardiomyopathies in 1994. To fulfill these criteria, presence of both electrocardiographic and anatomical abnormalities must be assessed with ECG and imaging techniques, respectively. This may be difficult in patients with early/mild forms of the disease as detectable structural abnormalities may still be absent. We evaluated in which patients presenting with right ventricular tachycardia (VT) serial reevaluation for ARVD/C is indicated. Sixty consecutive patients (41 men, mean age 40+/-15 years) were evaluated by the TF criteria for possible ARVD/C because of presentation with a left bundle branch block (LBBB) VT, representing 1 minor criterion. The presence on the ECG of a T-wave inversion beyond lead V2 (1 minor), right precordial QRS prolongation (1 major), or an epsilon wave (1 major) was assessed together with the visualization of severe regional/global right ventricle dysfunction (1 major) or mild segmental dilatation/regional hypokinesia (1 minor) by standard imaging techniques. Initially, 22 (37%) patients were diagnosed as having ARVD/C. After 47+/-39 (range 6-146) months, 23 initially TF-negative patients were reevaluated because of recurrent symptoms, with 12 (52%) additional patients now meeting the TF criteria. Eleven of these 12 (92%) patients presented initially with ECG abnormalities only, but developed structural abnormalities on imaging at follow-up. ECG abnormalities may precede structural abnormalities warranting serial reevaluation for ARVD/C in initially TF-negative patients presenting with LBBB VT with only ECG abnormalities.

Heart Rhythm, 2006

In patients late after surgical repair of congenital heart disease (CHD), areas with abnormal ele... more In patients late after surgical repair of congenital heart disease (CHD), areas with abnormal electrophysiologic properties may serve as slow conducting pathways within a macroreentrant circuit or may be the source of focal atrial tachycardia. The purpose of this study was to evaluate the role of abnormal areas during focal atrial tachycardia prior to ablation. Electroanatomic activation mapping of 62 atrial tachycardias was performed in 43 consecutive patients (37 +/- 12 years) after surgical repair of CHD. The mechanism of atrial tachycardia was scar related intra-atrial reentry (n = 27), cavotricuspid-related atrial flutter (n = 21), atrial fibrillation (n = 2), or focal atrial tachycardia (n = 10). During intra-atrial reentry, channels of slow conduction could be identified in all patients. Subsequent ablation was directed toward connecting two nonconductive borders. The site of origin during focal atrial tachycardia showed fractionated potentials and/or continuous electrical activity. Ablation directed at isolating the source area resulted in termination of focal atrial tachycardia in all cases. In two patients, ablation of an area showing continuous electrical activity giving rise to fibrillatory conduction resulted in termination of atrial fibrillation. Ablation of intra-atrial reentry was successful in 70%. Atrial flutter and focal atrial tachycardia were successfully ablated in all patients. No complications were observed. In patients with surgically corrected CHD, atrial tachycardia most often is caused by a macroreentrant mechanism but in some is the result of a focal mechanism. Areas of abnormal conduction may serve not only as a zone of slow conduction within a macroreentrant circuit but also as the site of origin of a focal atrial arrhythmia. Catheter ablation directed at "source isolation" is effective in eliminating focal atrial tachycardia in patients with CHD.

Europace, 2012

Recently, a multi-electrode catheter system using phased radiofrequency (RF) energy was developed... more Recently, a multi-electrode catheter system using phased radiofrequency (RF) energy was developed specifically for atrial fibrillation (AF) ablation: the pulmonary vein ablation catheter (PVAC), the multi-array septal catheter (MASC), and the multi-array ablation catheter (MAAC). Initial results of small trials have been promising: shorter procedure times and low adverse event rates. In a large single-centre registry, we evaluated the adverse events associated with multi-electrode ablation catheter procedures with PVAC alone, or combined with MASC and MAAC. Methods and results In all, 634 consecutive patients with AF had 663 procedures with multi-electrode ablation catheters, 502 patients with the PVAC alone, 128 patients with PVAC/MASC/MAAC, 29 redo procedures with the PVAC or PVAC/MASC/MAAC, and 4 patients had a complicated transseptal puncture. Major and minor adverse events during 6 month follow-up were registered. In 15 cases (2.3%), major adverse events were seen within the first month after the procedure. These included complicated transseptal puncture (4), stroke (2), transient ischaemic attack (5), acute coronary syndrome (2), femoral pseudoaneurysm (1), and arteriovenous fistulae (1). Minor adverse events were seen in 10.7% at 6 months, mostly due to femoral haematoma (3.9%), and non-significant PV stenosis (5.

Circulation, 2011

Background— Catheter ablation (CA) and minimally invasive surgical ablation (SA) have become acce... more Background— Catheter ablation (CA) and minimally invasive surgical ablation (SA) have become accepted therapy for antiarrhythmic drug–refractory atrial fibrillation. This study describes the first randomized clinical trial comparing their efficacy and safety during a 12-month follow-up. Methods and Results— One hundred twenty-four patients with antiarrhythmic drug–refractory atrial fibrillation with left atrial dilatation and hypertension (42 patients, 33%) or failed prior CA (82 patients, 67%) were randomized to CA (63 patients) or SA (61 patients). CA consisted of linear antral pulmonary vein isolation and optional additional lines. SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein, ganglionated plexi ablation, and left atrial appendage excision with optional additional lines. Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording. The primary end point, freedom from left atrial arrhythmia >30 seconds without antiarrhythmic d...

Circulation, 2006

Background— During heart development, the ventricular activation sequence changes from a base-to-... more Background— During heart development, the ventricular activation sequence changes from a base-to-apex to an apex-to-base pattern. We investigated the possibility of impulse propagation through remnants of atrioventricular (AV) connections in quail hearts. Methods and Results— In 86 hearts (group A, HH30–34, n=15; group B, HH35–44, n=65; group C, 5 to 6 months, n=6) electrodes were positioned at the left atrium, right ventricular base, left ventricular (LV) base, and LV apex. In group A, LV base activation preceded LV apex activation in the majority of cases (60%; 9 of 15), whereas hearts in group B primarily demonstrated an LV apex-to-base activation pattern (72%; 47 of 65). Interestingly, in group B, the right ventricular base (17%; 11 of 65) or LV base (8%; 5 of 65) exhibited premature activation in 25% (16 of 65) of cases, whereas in 26% (17 of 65), the right ventricular base or LV base was activated simultaneously with the LV apex. Morphological analysis confirmed functional dat...

Circulation, 2001

Background — Recently, the temporal excitable gap during atrial fibrillation (AF) has been identi... more Background — Recently, the temporal excitable gap during atrial fibrillation (AF) has been identified as a vulnerable parameter for cardioversion of AF. In this study, we evaluated 5 methods to measure the refractory period (RP AF ) and the excitable period (EP AF ) during persistent AF. Methods and Results — In 11 goats instrumented with 83 epicardial atrial electrodes, persistent AF (43±34 days) was induced with a median AF cycle length (CL) of 98±14 ms. To measure RP AF , premature stimuli were applied to the center of the electrode array on the right or left atrium. The RP AF measured by mapping of premature stimuli was 70±12 ms (“gold standard”). The RP AF determined during entrainment of AF was 77±17 ms ( R 2 =0.88, P <0.01). Statistical analysis of the effects of synchronized stimuli (each coupling interval ×100) on the AFCL histogram yielded an RP AF of 70±13 ms ( R 2 =0.94, P <0.01). A further simplification was to apply slow fixed-rate pacing (1 Hz) during AF. For ea...

Netherlands Heart Journal, 2021

Introduction The AcQMap High Resolution Imaging and Mapping System was recently introduced. This ... more Introduction The AcQMap High Resolution Imaging and Mapping System was recently introduced. This system provides 3D maps of electrical activation across an ultrasound-acquired atrial surface. Methods We evaluated the feasibility and the acute and short-term efficacy and safety of this novel system for ablation of persistent atrial fibrillation (AF) and atypical atrial flutter. Results A total of 21 consecutive patients (age (mean ± standard deviation) 62 ± 8 years, 23% female) underwent catheter ablation with the use of the AcQMap System. Fourteen patients (67%) were treated for persistent AF and 7 patients (33%) for atypical atrial flutter. Eighteen patients (86%) had undergone at least one prior ablation procedure. Acute success, defined as sinus rhythm without the ability to provoke the clinical arrhythmia, was achieved in 17 patients (81%). At 12 months, 4 patients treated for persistent AF (29%) and 4 patients treated for atypical flutter (57%) remained in sinus rhythm. Complic...

doi:10.1093/europace/eup221

Alaaddin Yilmaz, Mercedes Nadal, Elena Sandoval, Naiara Calvo, Josep Brugada, Lucas V.A. Boersma,... more Alaaddin Yilmaz, Mercedes Nadal, Elena Sandoval, Naiara Calvo, Josep Brugada, Lucas V.A. Boersma, Manuel Castella, WimJan van Boven, Antonio Berruezo, (FAST) : A 2-Center Randomized Clinical Trial Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment ISSN: 1524-4539 Copyright © 2011 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX published online November 14, 2011 Circulation http://circ.ahajournals.org/content/early/2011/11/13/CIRCULATIONAHA.111.074047 located on the World Wide Web at: The online version of this article, along with updated information and services, is

European Heart Journal, 2018

Atrial fibrillation ablation Methods: A total of 5011 patients with AF ablation were followed for... more Atrial fibrillation ablation Methods: A total of 5011 patients with AF ablation were followed for three years in Kansai Plus Atrial Fibrillation (KPAF) Registry. 4944 patients were not on HD (HD-group, 99%), and 67 patients were on HD (HD+ group, 1%). Sinus rhythm (SR) maintenance rate in HD-group and HD+ group was assessed with Kaplan-Meier method. Results: In HD-group, 2092 patients (42%) had ERs, and in HD+ group, 35 patients (52%) had ERs. There was no significant difference in the occurrence of ERs between two groups (p=0.10). In the patients with ERs, SR maintenance rate at three years after initial AF ablation in HD+ group (n=35) was significantly lower than in HD-group (n=2092) (11.4%, 35.5% respectively, log-rank p=0.005, see figure left). However, in the patients without ERs, there was no significant difference between two groups (log-rank p=0.62, see figure right). Figure 1 Conclusions: In HD patients, ER was a high risk of LR. However, if there was no ER, a good outcome was shown, as in the case without HD. P1911 The impact of manual vs remote magnetic navigation in the very long-term outcomes of catheter ablation of atrial fibrillation: a propensity score analysis

EP Europace, 2018

Left atrial appendage closure (LAAC) is increasingly used as an alternative to oral anticoagulati... more Left atrial appendage closure (LAAC) is increasingly used as an alternative to oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) patients. Feasibility and safety of left atrial (LA) catheter ablation (CA) in patients with previously implanted LAAC devices have not been well studied. We report on the feasibility, safety, and efficacy of LA CA in the presence of a previously implanted LAAC device.

EP Europace, 2016

Adenosine may unmask dormant pulmonary vein (PV) conduction after PVI. Its clinical impact remain... more Adenosine may unmask dormant pulmonary vein (PV) conduction after PVI. Its clinical impact remains controversial. This is the first study assessing adenosine challenge during PVI with the improved PVAC GOLD catheter, taking into account the recurrence of AF, localisation of dormant PV conduction and its relation with reconnection sites seen in repeated PVI during follow up. Methods: In this study, patients with symptomatic paroxysmal AF were included. After ostial PVI using PVAC GOLD catheter, adenosine (12 mg) was administered for each PV 20min after isolation. Presence and sites of dormant PV were noted. No additional ablation was performed. Results: A number of 172 patients were included (table). A total of 673 PV's were targeted. Ninety-seven (97) PV's in 71 patients (41%) showed dormant PV conduction. Common sites of reconnection were the left-sided carina (48%); 37% in the inferior site of the superior PV and 11% in the superior site of the inferior PV. Patients with dormant PV conduction showed in 26.8% recurrence of AF vs 16.8% without reconnection. In both groups 7 patients underwent repeated PVI. Reconduction sites corresponded with the localisation of the adenosine-provoked dormant PV conduction in 5 of 7 patients (71%); 6/7 patients also showed reconnection on other sites. Conclusion: Our study shows that patients with adenosine-provoked dormant PV conduction during PVI with PVAC GOLD catheter are more prone to recurrent AF. The sites of dormant conduction seem to be good predictors of the number and site of reconnected PV's needed to be ablated during repeated PVI due to recurrent AF. Table. Patient and procedural characteristics.

EP Europace, 2016

Purpose: cardiac resynchronization therapy (CRT) still has a significant non-response rate of 30%... more Purpose: cardiac resynchronization therapy (CRT) still has a significant non-response rate of 30%. In patients with atrial fibrillation (AF) the rate of non-responders is even higher, and few studies focused on this specific subgroup of patients. Triple-site pacing (Tri-V) is a new method of CRT which may help overcome these limitations. We aim to assess the effectiveness of this new type of CRT in patients with permanent AF. Methods: single-center prospective observational study of patients with permanent AF, NYHA class ! II and ejection fraction , 35% who underwent CRT implantion. 2 leads were implanted in the right ventricle, one in the apex and another in the outflow tract septal wall. A left ventricle lead was implanted as usual in a conventional CRT. Within 1 month after implantation, all patients underwent minimally invasive hemodynamic assessment using the Vigileo Flotracw (Edwards Lifesciences) for the determination of cardiac output in Tri-V or conventional biventricular pacing (Bi-V). The final mode (Tri-V vs Bi-V) was programmed according to the hemodynamic performance. Patients follow-up (FUP) was then undertaken at 6 and 12 months, and included clinical assessment with NYHA class determination, quality of life (Qol) assessment with the Minesota QoL questionaire, 6-minute walk test (6MWT) and echocardiogram with determination of the ejection fraction (EF). Patients were classified as responders if NYHA class was reduced by at least one level and EF increase of ! 10%, and as super-responders if NYHA class at FUP was I and EF ! 50%. Survival rates and survival free of heart failure hospitalization were calculated. For statistical analysis we used the paired samples T test. Summary of Results: we included 40 patients (93% male, mean age 72 + 10 years). 32 (80%) were programmed in Tri-V based on the hemodynamic test results. The following results pertain to this subgroup. At baseline, 58% of pts were in NYHA class III and 42% NYHA class II, with a mean ejection fraction of 28% + 5. After completion of 1 year of follow-up, mean QoL score more than halved (31 + 21 vs. 15 + 18; p ¼ 0,017 at 12 months), the 6MWT distance was significantly improved in the responder group (416 + 104 m to 465 + 107 m, p ¼ 0,005 at 12 months) and the mean ejection fraction also increased (28 + 5 vs. 40 + 10; p , 0,001 at 6 months and 28 + 5 vs. 41 + 10; p , 0,001 at 12 months). The responder rate was 62% at 6 months and 76% at 12 months. The super-responder rate was 9% at 6 months and 25% at 12 months. 4 pts died. Survival free of of heart failure hospitalization was 87,5%. Conclusion: Tri-V CRT yielded a high response rate, and a much higher super-response rate, than usually reported for conventional CRT in patients with permanent AF. There was a clear improvement in functional capacity and QoL, as well as positive reverse remodeling. These results may warrant considering Tri-V as a first line therapy in patients with permanent AF who are candidates for CRT, or as an upgrade option in non-responders.

Journal of cardiovascular electrophysiology, Jan 4, 2017

Optimal left ventricular (LV) lead position in patients undergoing cardiac resynchronization ther... more Optimal left ventricular (LV) lead position in patients undergoing cardiac resynchronization therapy(CRT) is crucial to achieve an optimal effect on hemodynamics. Due to various difficulties, up to 30% of transvenous LV lead placements fail, or a suboptimal position is achieved. Surgical epicardial LV lead placement could be performed at a position anticipated to be the optimal site. This could have a more favorable effect, which may be expressed by increased improvement in left ventricular ejection fraction(LVEF) and cardiac perfusion. The objective of this trial is to compare transvenous versus epicardial LV lead placement in CRT in a randomized fashion METHODS AND RESULTS: : 52 patients were randomized to either epicardial or transvenous approach. All patients received an ICD with CRT. Patients were followed for 6 months after device implant. Primary endpoint was the degree of change in cardiac perfusion measured by myocardial perfusion scintigraphy. LVEF equally improved in both...

Europace, 2016

A long-detection interval (LDI) (30/40 intervals) has been proved to be superior to a standard-de... more A long-detection interval (LDI) (30/40 intervals) has been proved to be superior to a standard-detection interval (SDI) (18/24 intervals) in terms of reducing unnecessary implantable cardioverter defibrillator (ICD) therapies. To better evaluate the different impact of LDI and anti-tachycardia pacing (ATP) on reducing painful shocks, we assessed all treated episodes in the ADVANCE III trial. Methods and results A total of 452 fast (200 ms , cycle length ≤ 320 ms) arrhythmic episodes were recorded: 284 in 138 patients in the SDI arm and 168 in 82 patients in the LDI arm (106/452 inappropriate detections). A total of 346 fast ventricular tachycardias (FVT) were detected in 169 patients: 208 in 105 patients with SDI and 138 in 64 patients with LDI. Setting LDI determined a significant reduction in appropriate but unnecessary therapies [208 in SDI vs. 138 in LDI; incidence rate ratio (IRR): 0.61 (95% CI 0.45-0.83), P ¼ 0.002]. Anti-tachycardia pacing determined another 52% reduction in unnecessary shocks [208 in SDI with hypothetical shock-only programming vs. 66 in LDI with ATP; IRR: 0.37 (95% CI 0.25-0.53, P , 0.001)]. The efficacy of ATP in terminating FVT was 63% in SDI and 52% in LDI (P ¼ 0.022). No difference in the safety profile (acceleration/degeneration and death/cardiovascular hospitalizations) was observed between the two groups. Conclusion The combination of LDI and ATP during charging is extremely effective and significantly reduces appropriate but unnecessary therapies. The use of LDI alone yielded a 39% reduction in appropriate but unnecessary therapies; ATP on top of LDI determined another 52% reduction in unnecessary shocks. The strategy of associating ATP and LDI could be considered in the majority of ICD recipients.

Circulation: Arrhythmia and Electrophysiology, 2016

Background— Single-shot ablation techniques may facilitate safe and simple pulmonary vein isolati... more Background— Single-shot ablation techniques may facilitate safe and simple pulmonary vein isolation to treat paroxysmal atrial fibrillation. Multielectrode pulmonary vein isolation versus single tip wide area catheter ablation-paroxysmal atrial fibrillation is the first multinational, multicenter, prospective, noninferiority randomized clinical trial comparing multielectrode-phased radiofrequency ablation (MEA) to standard focal irrigated radiofrequency ablation (STA) using 3-dimensional navigation. Methods and Results— Patients with paroxysmal atrial fibrillation were randomized to MEA (61 patients) or STA (59 patients). Preprocedure transesophageal echocardiogram and computed tomography/magnetic resonance imaging (also 6-month postprocedure) were performed. Mean age was 57 years, 25% female sex, BMI was 28, CHA 2 DS 2 –VASc score was 0 to 1 in 82%, 8% had previous right atrial ablation, whereas all had at least 1 antiarrhythmic drug failure. The MEA group had significantly shorter...

Monophasic Action Potentials, 1997

It has long been known that atrial fibrillation (AF) is a progressive disease. While it may first... more It has long been known that atrial fibrillation (AF) is a progressive disease. While it may first reveal itself in the form of shorter or longer paroxysms of AF, in many cases after some time atrial fibrillation no longer terminates spontaneously and the arrhythmia becomes persistent. Finally, as an endstage, atrial fibrillation can no longer be deflbrillated, or the arrhythmia recurs almost immediately after defibrillation (permanent AF). Mauricio Rosenbaum has coined the term “domestication of atrial fibrillation” to describe the clinical observation that instead of remaining a sinus rhythm, at a certain given moment AF becomes the predominant rhythm. There is little doubt that the natural history of AF, to a large extent is due to the progression of pathological anatomical changes in the atria either due to age (fibrosis, fatty degeneration), or an underlying heart disease (mitral valve disease, hypertension, coronary atherosclerosis). On the other hand the possibility should be considered that, irrespective of the progression of an underlying heart disease, atrial fibrillation per se might cause progressive changes to either the structure or the electrophysiological properties of the atria (electrical remodeling).

Journal of Interventional Cardiac Electrophysiology, 2013

The pulmonary vein ablation catheter (PVAC) is designed for pulmonary vein isolation (PVI). Elect... more The pulmonary vein ablation catheter (PVAC) is designed for pulmonary vein isolation (PVI). Electrical reconnection of pulmonary veins is believed to result in AF recurrence. The purpose of this study was to establish the location and extent of PV reconnection after PVI with the PVAC catheter. Eighty-two patients (79 % male, age 60 ± 9 years) that underwent a redo procedure for recurrent AF after PVAC ablation were assessed for prevalence and location of reconnection. The number of reconnected PV&#39;s was 0, 1, 2, 3, or 4 in 2 (2.4 %), 14 (17 %), 23 (28 %), 28 (34 %), and 15 (18 %) patients, respectively. Reconnection of left superior, left inferior, left common, right superior, and right inferior PV&#39;s was found in 66, 63, 83, 57, and 67 %, respectively (p = 0.48). In the left PV&#39;s, reconnection was located significantly more anterior than posterior; LSPV anterior 32/70 vs posterior 13/70 (p &lt; 0.01), LIPV anterior 26/70 vs posterior 9/70 (p &lt; 0.01). In the right PV&#39;s reconnection was distributed equally in all quadrants. Different modes of RF delivery during PVAC ablation (bipolar/unipolar 2:1 [n = 35] vs. 4:1 [n = 47]) yielded comparable rates of PV reconnection. During follow-up (median 296 days) no AF/AT was documented in 57 patients (70 %). Almost all patients (98 %) with AF after PVAC ablation show reconnection of at least one PV. All PV&#39;s are equally likely to show reconnection. In the left PV&#39;s, reconnection was found more often anteriorly than posteriorly. During pulmonary vein isolation with the PVAC catheter, prevalent sites of reconnection deserve close attention to increase success.

Journal of Cardiovascular Electrophysiology, 2009

ADVANCE III Trial. Introduction: The purpose of this investigation is to evaluate whether a prolo... more ADVANCE III Trial. Introduction: The purpose of this investigation is to evaluate whether a prolonged detection interval for life threatening ventricular tachyarrhythmia (VT) is able to reduce therapies (Rx) delivered by an implantable cardioverter/defibrillator (ICD). Until now, only the PREPARE trial demonstrated a reduction of ICD Rx in a cohort of primary prevention patients. Methods and Results: The ADVANCE III study is a prospective, randomized, parallel trial with 2 arms evaluating different intervals to detect (NID), i.e., 18/24 (as currently used) versus 30/40. The primary endpoint is to demonstrate a 20% reduction of ICD Rx (antitachycardia pacing or shocks) delivered to terminate spontaneous VT with a cycle length ≤320 ms in patients with Class I-IIA indication for ICD therapy, regardless of cardiac resynchronization capabilities. The worldwide investigation started in spring 2008 and is expected to be finished in 2011. Conclusions: The ADVANCE III trial is the first randomized investigation evaluating the reduction of ICD Rx for fast VT due to a prolongation of NID in a general ICD patient cohort.

Journal of Cardiovascular Electrophysiology, 2006

Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is based on a set... more Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is based on a set of criteria proposed by the International Task Force (TF) for Cardiomyopathies in 1994. To fulfill these criteria, presence of both electrocardiographic and anatomical abnormalities must be assessed with ECG and imaging techniques, respectively. This may be difficult in patients with early/mild forms of the disease as detectable structural abnormalities may still be absent. We evaluated in which patients presenting with right ventricular tachycardia (VT) serial reevaluation for ARVD/C is indicated. Sixty consecutive patients (41 men, mean age 40+/-15 years) were evaluated by the TF criteria for possible ARVD/C because of presentation with a left bundle branch block (LBBB) VT, representing 1 minor criterion. The presence on the ECG of a T-wave inversion beyond lead V2 (1 minor), right precordial QRS prolongation (1 major), or an epsilon wave (1 major) was assessed together with the visualization of severe regional/global right ventricle dysfunction (1 major) or mild segmental dilatation/regional hypokinesia (1 minor) by standard imaging techniques. Initially, 22 (37%) patients were diagnosed as having ARVD/C. After 47+/-39 (range 6-146) months, 23 initially TF-negative patients were reevaluated because of recurrent symptoms, with 12 (52%) additional patients now meeting the TF criteria. Eleven of these 12 (92%) patients presented initially with ECG abnormalities only, but developed structural abnormalities on imaging at follow-up. ECG abnormalities may precede structural abnormalities warranting serial reevaluation for ARVD/C in initially TF-negative patients presenting with LBBB VT with only ECG abnormalities.

Heart Rhythm, 2006

In patients late after surgical repair of congenital heart disease (CHD), areas with abnormal ele... more In patients late after surgical repair of congenital heart disease (CHD), areas with abnormal electrophysiologic properties may serve as slow conducting pathways within a macroreentrant circuit or may be the source of focal atrial tachycardia. The purpose of this study was to evaluate the role of abnormal areas during focal atrial tachycardia prior to ablation. Electroanatomic activation mapping of 62 atrial tachycardias was performed in 43 consecutive patients (37 +/- 12 years) after surgical repair of CHD. The mechanism of atrial tachycardia was scar related intra-atrial reentry (n = 27), cavotricuspid-related atrial flutter (n = 21), atrial fibrillation (n = 2), or focal atrial tachycardia (n = 10). During intra-atrial reentry, channels of slow conduction could be identified in all patients. Subsequent ablation was directed toward connecting two nonconductive borders. The site of origin during focal atrial tachycardia showed fractionated potentials and/or continuous electrical activity. Ablation directed at isolating the source area resulted in termination of focal atrial tachycardia in all cases. In two patients, ablation of an area showing continuous electrical activity giving rise to fibrillatory conduction resulted in termination of atrial fibrillation. Ablation of intra-atrial reentry was successful in 70%. Atrial flutter and focal atrial tachycardia were successfully ablated in all patients. No complications were observed. In patients with surgically corrected CHD, atrial tachycardia most often is caused by a macroreentrant mechanism but in some is the result of a focal mechanism. Areas of abnormal conduction may serve not only as a zone of slow conduction within a macroreentrant circuit but also as the site of origin of a focal atrial arrhythmia. Catheter ablation directed at &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;source isolation&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; is effective in eliminating focal atrial tachycardia in patients with CHD.

Europace, 2012

Recently, a multi-electrode catheter system using phased radiofrequency (RF) energy was developed... more Recently, a multi-electrode catheter system using phased radiofrequency (RF) energy was developed specifically for atrial fibrillation (AF) ablation: the pulmonary vein ablation catheter (PVAC), the multi-array septal catheter (MASC), and the multi-array ablation catheter (MAAC). Initial results of small trials have been promising: shorter procedure times and low adverse event rates. In a large single-centre registry, we evaluated the adverse events associated with multi-electrode ablation catheter procedures with PVAC alone, or combined with MASC and MAAC. Methods and results In all, 634 consecutive patients with AF had 663 procedures with multi-electrode ablation catheters, 502 patients with the PVAC alone, 128 patients with PVAC/MASC/MAAC, 29 redo procedures with the PVAC or PVAC/MASC/MAAC, and 4 patients had a complicated transseptal puncture. Major and minor adverse events during 6 month follow-up were registered. In 15 cases (2.3%), major adverse events were seen within the first month after the procedure. These included complicated transseptal puncture (4), stroke (2), transient ischaemic attack (5), acute coronary syndrome (2), femoral pseudoaneurysm (1), and arteriovenous fistulae (1). Minor adverse events were seen in 10.7% at 6 months, mostly due to femoral haematoma (3.9%), and non-significant PV stenosis (5.

Circulation, 2011

Background— Catheter ablation (CA) and minimally invasive surgical ablation (SA) have become acce... more Background— Catheter ablation (CA) and minimally invasive surgical ablation (SA) have become accepted therapy for antiarrhythmic drug–refractory atrial fibrillation. This study describes the first randomized clinical trial comparing their efficacy and safety during a 12-month follow-up. Methods and Results— One hundred twenty-four patients with antiarrhythmic drug–refractory atrial fibrillation with left atrial dilatation and hypertension (42 patients, 33%) or failed prior CA (82 patients, 67%) were randomized to CA (63 patients) or SA (61 patients). CA consisted of linear antral pulmonary vein isolation and optional additional lines. SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein, ganglionated plexi ablation, and left atrial appendage excision with optional additional lines. Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording. The primary end point, freedom from left atrial arrhythmia >30 seconds without antiarrhythmic d...

Circulation, 2006

Background— During heart development, the ventricular activation sequence changes from a base-to-... more Background— During heart development, the ventricular activation sequence changes from a base-to-apex to an apex-to-base pattern. We investigated the possibility of impulse propagation through remnants of atrioventricular (AV) connections in quail hearts. Methods and Results— In 86 hearts (group A, HH30–34, n=15; group B, HH35–44, n=65; group C, 5 to 6 months, n=6) electrodes were positioned at the left atrium, right ventricular base, left ventricular (LV) base, and LV apex. In group A, LV base activation preceded LV apex activation in the majority of cases (60%; 9 of 15), whereas hearts in group B primarily demonstrated an LV apex-to-base activation pattern (72%; 47 of 65). Interestingly, in group B, the right ventricular base (17%; 11 of 65) or LV base (8%; 5 of 65) exhibited premature activation in 25% (16 of 65) of cases, whereas in 26% (17 of 65), the right ventricular base or LV base was activated simultaneously with the LV apex. Morphological analysis confirmed functional dat...

Circulation, 2001

Background — Recently, the temporal excitable gap during atrial fibrillation (AF) has been identi... more Background — Recently, the temporal excitable gap during atrial fibrillation (AF) has been identified as a vulnerable parameter for cardioversion of AF. In this study, we evaluated 5 methods to measure the refractory period (RP AF ) and the excitable period (EP AF ) during persistent AF. Methods and Results — In 11 goats instrumented with 83 epicardial atrial electrodes, persistent AF (43±34 days) was induced with a median AF cycle length (CL) of 98±14 ms. To measure RP AF , premature stimuli were applied to the center of the electrode array on the right or left atrium. The RP AF measured by mapping of premature stimuli was 70±12 ms (“gold standard”). The RP AF determined during entrainment of AF was 77±17 ms ( R 2 =0.88, P <0.01). Statistical analysis of the effects of synchronized stimuli (each coupling interval ×100) on the AFCL histogram yielded an RP AF of 70±13 ms ( R 2 =0.94, P <0.01). A further simplification was to apply slow fixed-rate pacing (1 Hz) during AF. For ea...