Paolo Di Donna - Academia.edu (original) (raw)
Papers by Paolo Di Donna
Italian heart journal : official journal of the Italian Federation of Cardiology, 2003
Radiofrequency catheter ablation is nowadays a widely used technique for the treatment of arrhyth... more Radiofrequency catheter ablation is nowadays a widely used technique for the treatment of arrhythmias; however, due to the possible complications such as atrioventricular block when radiofrequency is delivered in the septal area, this type of energy is not optimal. In contrast, cryoenergy has several positive features; first of all, it allows for the creation of reversible lesions and hence to test the effects of the ablation while the lesion is still forming thus reducing the number of ineffective and useless lesions. In addition, it also allows for the evaluation of the acute effects on the structures adjacent to the ablation site. The aim of the present study was to analyze the effectiveness and safety of catheter cryoablation in the treatment of atrioventricular nodal reentrant tachycardia (AVNRT). Thirty-two patients presenting with AVNRT underwent catheter cryoablation using a 7F catheter. When the optimal parameters were recorded, "ice mapping" at -30 degrees C was ...
Circulation. Arrhythmia and electrophysiology, 2008
Data regarding the long-term efficacy of atrial fibrillation (AF) ablation are still lacking. Two... more Data regarding the long-term efficacy of atrial fibrillation (AF) ablation are still lacking. Two hundred four consecutive patients symptomatic for paroxysmal or persistent/permanent AF were randomly assigned to 2 different ablation schemes: pulmonary vein isolation (PVI) and PVI plus left linear lesions (LL). Primary end point was to assess the maintenance of sinus rhythm (SR) after procedures 1 and 2 in the absence of antiarrhythmic drugs in a long-term follow-up of at least 3 years. Paroxysmal AF- With a single procedure at 12-month follow-up, 46% of patients treated with PVI maintained SR, whereas at 3-year follow-up, 29% were in SR; using the "PVI plus LL" at the 12-month follow-up, 57% of patients were in SR, whereas at the 3-year follow-up, 53% remained in SR. After a second procedure, the long-term overall success rate without antiarrhythmic drugs was 62% with PVI and 85% with PVI plus LL. Persistent/Permanent AF- With a single procedure at the 12-month follow-up, ...
Giornale italiano di cardiologia (2006), 2009
Atrial fibrillation (AF) is the most frequent supraventricular arrhythmia. It is associated with ... more Atrial fibrillation (AF) is the most frequent supraventricular arrhythmia. It is associated with increased morbidity and mortality but its management is still under debate. The limited success of drug treatment has stimulated an exploration of interventional treatment options. Therefore, in the past decade, various ablative procedures, both surgical and transcatheter, have been proposed. Catheter ablation has involved mainly patients without structural heart disease. In the series published to date the percentage of patients with structural heart disease undergoing catheter ablation for AF is about 20%. These patients would benefit the most from the maintenance of sinus rhythm but on the other hand data show a higher post-procedural recurrence rate. In patients with valvular heart disease and indication to surgical repair or valvular replacement, surgical ablation is indicated in the majority of cases. Catheter ablation in patients with heart failure and AF should be considered when...
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, 2014
Atrial tachycardias are common after repair of atrial septal defect (ASD). Although ablation has ... more Atrial tachycardias are common after repair of atrial septal defect (ASD). Although ablation has shown promising results in the short and mid-term follow-up, little data regarding the very long-term success exist. Our aim was to assess very long-term follow-up in patients who have undergone electroanatomic-guided radiofrequency (RF) ablation of late-onset atrial arrhythmias after ASD surgery. Forty-six consecutive patients with surgically repaired ASD were referred for atrial tachycardia ablation. Electrophysiological (EP) study and ablation procedure with the aid of an electroanatomic mapping (EAM) system were performed. Mean age was 49 ± 13 years (females 61%). The presenting arrhythmias were typical atrial flutter (48%), atypical atrial flutter (35%), and atrial tachycardia (17%). In 41% of patients, atrial fibrillation was also present. The EP study showed a right atrial macroreentrant circuit in all the patients. In 12 of 46 (26%), the circuit was localized in the cavo-tricuspi...
Italian heart journal : official journal of the Italian Federation of Cardiology, 2002
This study investigated whether a minimal approach to typical atrial flutter ablation using an 8 ... more This study investigated whether a minimal approach to typical atrial flutter ablation using an 8 mm tip catheter with a 150 W generator with only the documentation of clockwise block by means of local criteria predicts a good long-term outcome. Seventy patients underwent typical atrial flutter ablation. A multipolar catheter was inserted into the coronary sinus (CS) and an 8 mm tip ablation catheter was used to ablate and map the isthmus. The ablation line was performed in the posteroseptal region. The clockwise block was confirmed by recording a corridor of double potentials along the line and by counterclockwise activation of the portion of the isthmus just beyond the lesion line as demonstrated by measuring the conduction times during CS pacing. In case of block, the mean distance between the two split atrial electrograms was 129 +/- 31 ms. Acute isthmus block was achieved in all 70 patients. The median of the radiofrequency pulses was 10 (range 1-36). No immediate or late compli...
Pacing and Clinical Electrophysiology, 2015
Background. Fluoroscopic catheter ablation of cardiac arrhythmias in pediatric patients exposes t... more Background. Fluoroscopic catheter ablation of cardiac arrhythmias in pediatric patients exposes the patients to the potential risk of radiation considering the sensitivity of this population and its longer life expectancy. We evaluated the feasibility, safety and efficacy of accessory pathway (AP) ablation guided by CARTO3 electroanatomic mapping (EAM) system with both cryoenergy and radiofrequency (RF) energy in order to avoid x-ray exposure in pediatric patients.
International Journal of Cardiac Imaging, 2000
should read:
Global Cardiology Science and Practice, 2013
CLINICAL CASE This is a case of a 50-year-old woman complaining of easy fatigability, anorexia an... more CLINICAL CASE This is a case of a 50-year-old woman complaining of easy fatigability, anorexia and hypotension since 2009. She also reported alopecia, a 15 kg weight loss, and amenorrhea. A year after the beginning of the symptoms she sought medical attention: a diagnosis of nephrotic syndrome with proteinuria . 10 g/L was made. A renal biopsy showed focal segmental glomerulosclerosis. Steroids and cyclosporin were then started. The patient did quite well until November 2011 when she was hospitalized for the recurrence of the symptoms. Because of persistent hypotension, Rituximab therapy instead of Bortezumib was instituted. At that time the ECG showed sinus rhythm with low QRS voltages and Q waves in the inferior leads and from V1 to V4. An echocardiogram showed severe symmetric left ventricular hypertrophy (21 mm of the interventricular septum and 20 mm of the posterior wall diastolic thickness). The left ventricular walls showed an inhomogeneous granular pattern. During systole, a virtual left ventricular cavity was evident with a left ventricular ejection fraction (LVEF) around 60%. A severe dynamic left ventricular outflow tract (LVOT) obstruction was present with a left ventricularaortic gradient of 120 mmHg at rest and 250 mmHg during the Valsalva maneuver. Moderate mitral regurgitation with a systolic anterior motion (SAM) of the mitral valve was demonstrated. Severe diastolic dysfunction was present, with an E/E' ratio of 12.3 cm/s ( ).
Journal of Cardiovascular Electrophysiology, 2014
Background: Simultaneous multipolar ablation catheters have been proposed to simplify pulmonary v... more Background: Simultaneous multipolar ablation catheters have been proposed to simplify pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (AF). Recently, a new multipolar irrigated radiofrequency (RF) ablation catheter (nMARQ TM , Biosense Webster Inc, Diamond Bar, California) combining both three-dimensional electroanatomic mapping and multipolar open-irrigated ablation capability has been developed. Aim of our study was to assess feasibility, acute and short-term success and safety of PVI by the use of this new technology with particular regard to the incidence of post-ablation silent cerebral ischemia (SCI).
Journal of Cardiovascular Medicine, 2010
To assess retrospectively clinical and procedural predictors of long-term recurrences after atria... more To assess retrospectively clinical and procedural predictors of long-term recurrences after atrial fibrillation ablation. Two hundred and forty consecutive patients (201 men; mean age 60 +/- 10 years) undergoing pulmonary vein isolation (PVI) plus linear lesion ablation for antiarrhythmic drug-refractory atrial fibrillation between 2005 and 2007 were studied. Magnetic resonance imaging of the left atrium was performed in all the patients. Patients were followed up with clinical examination and ECG Holter at 1, 3, 6 months and every 6 months thereafter. In case of recurrence, a second procedure was offered. Clinical and procedural data were evaluated with univariate and multivariate analysis. At a mean follow-up of 30.3 +/- 9.2 months after one or two procedures, 99 (41.3%) patients were in sinus rhythm without antiarrhythmic drugs and 50 patients (20.8%) had arrhythmia recurrences. These groups were compared in order to identify the clinical predictors of recurrences. Variables directly related to failure at univariate analysis were: history of persistent atrial fibrillation, number of previous electrical cardioversions, left atrial volume (LAV) at MRI, presence of pulmonary vein anatomical variants and BMI. At multivariate analysis, only left atrial volume measured at MRI was an independent predictor of failure. With long-term follow-up, LAV at MRI represents the main determinant of outcome after PVI plus linear lesion for ablation of paroxysmal and persistent atrial fibrillation.
Pacing and Clinical Electrophysiology, 2013
Anatomical considerations and risks related to x-ray exposure make atrioventricular nodal reentra... more Anatomical considerations and risks related to x-ray exposure make atrioventricular nodal reentrant tachycardia (AVNRT) ablation in pediatric patients a concerning procedure. We aimed to evaluate the feasibility, safety, and efficacy of performing fluoroless slow-pathway cryoablation guided by the electroanatomic (EA) mapping in children and adolescents. Twenty-one consecutive patients (mean age 13.5 ± 2.4 years) symptomatic for AVNRT were prospectively enrolled to right atrium EA mapping and electrophysiological study prior to cryoablation. Cryoablation was guided by slow-pathway potential and performed using a 4-mm-tip catheter. Sustained slow-fast AVNRT was inducible in all the patients with a dual AV nodal physiology in 95%. Acute success was achieved in 100% of the patients with a median of two cryo-applications. Fluoroless ablation was feasible in 19 patients, while in two subjects 50 seconds and 45 seconds of x-ray were needed due to difficult progression of the catheters along the venous system. After a mean follow-up of 25 months, AVNRT recurred in five patients. All the recurrences were successfully treated with a second procedure. In three patients, a fluoroless cryoablation with a 6-mm-tip catheter was successfully performed, while in the remaining two patients, a single pulse of 60 seconds of radiofrequency energy was applied under fluoroscopic monitoring. No complications occurred. Combination of EA mapping systems and cryoablation may allow to perform fluoroless slow-pathway ablation for AVNRT in children and adolescents in the majority of patients. Fluoroless slow-pathway cryoablation showed a high efficacy and safety comparable to conventional fluoroscopy guided procedures.
Journal of the American College of Cardiology, 2001
We aimed to evaluate: 1) the behavior of electrical activity simultaneously in different atrial r... more We aimed to evaluate: 1) the behavior of electrical activity simultaneously in different atrial regions during atrial fibrillation (AF); 2) the difference of atrial activation between paroxysmal and chronic AF; 3) the atrial refractoriness dispersion; and 4) the correlation between the effective refractory periods (ERPs) and the FF intervals. BACKGROUND Little data exist on the electrophysiologic characteristics of the different atrial regions in patients with AF. A more detailed knowledge of the electrical activity during AF may provide further insights to improve treatment of AF.
Journal of the American College of Cardiology, 2001
Journal of the American College of Cardiology, 2000
We sought to evaluate whether a limited surgical cryoablation of the posterior region of the left... more We sought to evaluate whether a limited surgical cryoablation of the posterior region of the left atrium was safe and effective in the cure of atrial fibrillation (AF) in patients with associated valvular heart disease. BACKGROUND Extensive surgical ablation of AF is a complex and risky procedure. The posterior region of the left atrium seems to be important in the initiation and maintenance of AF.
Journal of Cardiovascular Electrophysiology, 2000
Atrial Flutter Mapping. Introduction: The aim of this study was to map the low right atrium befor... more Atrial Flutter Mapping. Introduction: The aim of this study was to map the low right atrium before and after radiofrequency ablation of the inferior vena tava-tricuspid annulus (IVC-TA) isthmus in patients with typical atrial flutter (AFI) to better understand the electrophysiologic meaning of incomplete or unidirectional block following the ahlation procedure and its relationship with AFI recurrence.
Journal of Cardiovascular Electrophysiology, 2012
Catheter Design and Anticoagulation on Postablation Silent Cerebral Ischemia. Introduction: Silen... more Catheter Design and Anticoagulation on Postablation Silent Cerebral Ischemia. Introduction: Silent cerebral lesions (SCL) are a sensitive tool to evaluate thromboembolic risk of catheter ablation. Recent data showed the possibility to reduce thrombus formation when the electrode-tissue interface cooling is optimized by a homogeneous flushing of saline along the entire surface of the distal electrode through a larger number of irrigation holes. The study aim is to compare procedural parameters and safety of pulmonary vein isolation (PVI) performed by using open-irrigated catheters with different irrigation design.
International Journal of Cardiology, 2013
Background: The 12-lead electrocardiogram (ECG) is considered an essential screening tool for hyp... more Background: The 12-lead electrocardiogram (ECG) is considered an essential screening tool for hypertrophic cardiomyopathy (HCM). A vast array of ECG abnormalities has been described in HCM, although their relationship to left ventricle (LV) morphology and degree of hypertrophy appears elusive. Aim of this study was to assess the relationship of ECG patterns with the HCM phenotype assessed according to the novel opportunities offered by cardiac magnetic imaging (CMR). Methods: CMR and 12-lead ECG were performed in 257 HCM patients. Severity of ECG abnormalities was defined by the sum of 9 criteria: abnormal cardiac rhythm, QRS duration ≥ 100 ms, Romhilt-Estes score ≥ 5, fascicular block (LAHB) and/or bundle-branch block (LBBB or RBBB), ST-T abnormalities, ST-T segment elevation ≥ 0.2 mV, prolonged QTc interval, pathological Q waves, absence of normal Q wave. Four ECG groups were identified: normal (0 criteria); mildly abnormal (1-3 criteria); moderately abnormal (4-6 criteria); markedly abnormal (7-9 criteria). Results: There was a direct relationship between severity of ECG abnormalities and HCM phenotype. LV mass index was normal in most patients with normal ECG and progressively increased with each class of ECG score, from 70.9 ± 18.6 g/m 2 in patients with normal ECG to 107.1 ± 55.1 g/m 2 among those with markedly abnormal ECG (p = b 0.0001). Likewise, the prevalence and extent of late gadolinium enhancement (LGE) increased significantly with the ECG score, from 37% in patients with normal ECG to 93% in patients with markedly abnormal ECG (overall p = 0.0012). A normal ECG had a negative predictive accuracy of 96% for markedly increased LV mass (> 91 g/m 2 for men and >69 g/m 2 for women), and of 100% for maximum LV thickness ≥ 30 mm. Conclusions: In a large HCM cohort, the number and severity of ECG abnormalities were directly related to phenotypic expression as revealed by CMR. Although false negative ECG findings remain a challenge in population screenings for HCM, a normal ECG proved effective in ruling out severe LV hypertrophy, suggesting potential implications for long-term follow-up of HCM patients and family members. A simple score for quantification of ECG abnormalities in HCM patients is proposed.
Europace, 2010
In patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF), radiofrequency c... more In patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF), radiofrequency catheter ablation (RFCA) represents a promising option. However, the predictors of RFCA efficacy remain largely unknown. We assessed the outcome of a multicentre HCM cohort following RFCA for symptomatic AF refractory to medical therapy. Sixty-one patients (age 54 +/- 13 years; time from AF onset 5.7 +/- 5.5 years) with paroxysmal (n = 35; 57%), recent persistent (n = 15; 25%), or long-standing persistent AF (n = 11; 18%) were enrolled. A scheme with pulmonary vein isolation plus linear lesions was employed. Of the 61 patients, 32 (52%) required redo procedures. Antiarrhythmic therapy was maintained in 22 (54%). At the end of a 29 +/- 16 months follow-up, 41 patients (67%) were in sinus rhythm, including 17 of the 19 patients aged < or = 50 years, with marked improvement in New York Heart Association (NYHA) functional class (1.2 +/- 0.5 vs. 1.9 +/- 0.7 at baseline; P < 0.001). In the remaining 20 patients (33%), with AF recurrence, there was less marked, but still significant, improvement following RFCA (NYHA class 1.8 +/- 0.7 vs. 2.3 +/- 0.7 at baseline; P = 0.002). Independent predictors of AF recurrence were increased left atrium volume [hazard ratio (HR) per unit increase 1.009, 95% confidence interval (CI) 1.001-1.018; P = 0.037] and NYHA functional class (HR 2.24, 95% CI 1.16-4.35; P = 0.016). Among 11 genotyped HCM patients (6 with MYBPC3, 2 with MYH7, 1 with MYL2 and 2 with multiple mutations), RFCA success rate was comparable with that of the overall cohort (n = 8; 73%). RFCA was successful in restoring long-term sinus rhythm and improving symptomatic status in most HCM patients with refractory AF, including the subset with proven sarcomere gene mutations, although redo procedures were often necessary. Younger HCM patients with small atrial size and mild symptoms proved to be the best RFCA candidates, likely due to lesser degrees of atrial remodelling.
Europace, 2011
Atrial fibrillation (AF) ablation still requires long procedural time and high radiation exposure... more Atrial fibrillation (AF) ablation still requires long procedural time and high radiation exposure with its related risk for the patient and the operators. This study was designed to compare three different approaches of AF ablation to verify the hypothesis that image integration with electroanatomic mapping allows minimal use of fluoroscopy. Therefore, we evaluated the procedure and fluoroscopy times of ablation using three imaging modalities: conventional fluoroscopy, image integration electroanatomic mapping, and a new electroanatomic mapping system that provides visualization of multiple catheters. One hundred and twenty patients with symptomatic refractory AF were enrolled in the study. Patients were randomly assigned to fluoroscopy alone (Group A, 40 patients), electroanatomic integration (Cartomerge®, Group B, 40 patients), and electroanatomic integration plus catheters visualization (Carto® 3 System, Group C, 40 patients) guided procedures. The ablation procedure aimed at isolating the pulmonary veins and creating lesion lines at the left atrial roof and left isthmus. Procedure and fluoroscopy parameters were recorded in all patients. Total procedure time and skin to catheter positioning time did not significantly differ between the groups. Total fluoroscopy time was statistically different between all three groups (Group A, 18'09″±5'00″; Group B, 9'48″±3'41″; Group C, 2'28″±1'40″; P<0.001). A significant difference was noted in ablation fluoroscopy time between all groups (P<0.001), mainly due to shortened fluoroscopy time in Group B (7'34″±3'15″) and Group C (0'21″±0'31″) when compared with Group A (16'07″±5'04″). Image integration and, to a larger extent, visualization of multiple catheters allowed a minimal use of fluoroscopy in transcatheter AF ablation.
Europace, 2004
Aims To verify if sites of conduction gaps on the isthmus correlate with anatomical peculiarities... more Aims To verify if sites of conduction gaps on the isthmus correlate with anatomical peculiarities using the intracardiac echo (ICE) and a new 3D device to reconstruct the isthmus in patients undergoing cavotricuspid isthmus ablation. Methods and results Twenty patients underwent isthmus ablation using an 8 mm tip ablation catheter. Two-dimensional and 3D ICE reconstruction of the isthmus was made before, during and after ablation. At the end of the lesion line isthmus block was validated by electrophysiological criteria. In case of its absence we closed the remaining conduction gaps verifying the position of the sites with ICE. Fourteen patients required a median of 8 RF pulses to obtain complete isthmus block (Group A). In the remaining 6 patients isthmus block was obtained with a median of 25 RF pulses due to conduction gaps 'resistant' to ablation (Group B). Conduction gap positions assessed by ICE were located in the central portion of the isthmus below the coronary sinus os in 71% of cases in Group A and along a prominent Eustachian ridge in Group B patients, respectively. 3D reconstruction showed a smooth isthmus in Group A with a 'peak and valleys' isthmus in Group B. In these latter patients isthmus block was obtained only after the complete ablation of the prominent Eustachian ridge. Conclusion The isthmus presents anatomical variants particularly due to Eustachian ridge peculiarities which may represent a site of conduction gaps ''resistant'' to ablation.
Italian heart journal : official journal of the Italian Federation of Cardiology, 2003
Radiofrequency catheter ablation is nowadays a widely used technique for the treatment of arrhyth... more Radiofrequency catheter ablation is nowadays a widely used technique for the treatment of arrhythmias; however, due to the possible complications such as atrioventricular block when radiofrequency is delivered in the septal area, this type of energy is not optimal. In contrast, cryoenergy has several positive features; first of all, it allows for the creation of reversible lesions and hence to test the effects of the ablation while the lesion is still forming thus reducing the number of ineffective and useless lesions. In addition, it also allows for the evaluation of the acute effects on the structures adjacent to the ablation site. The aim of the present study was to analyze the effectiveness and safety of catheter cryoablation in the treatment of atrioventricular nodal reentrant tachycardia (AVNRT). Thirty-two patients presenting with AVNRT underwent catheter cryoablation using a 7F catheter. When the optimal parameters were recorded, "ice mapping" at -30 degrees C was ...
Circulation. Arrhythmia and electrophysiology, 2008
Data regarding the long-term efficacy of atrial fibrillation (AF) ablation are still lacking. Two... more Data regarding the long-term efficacy of atrial fibrillation (AF) ablation are still lacking. Two hundred four consecutive patients symptomatic for paroxysmal or persistent/permanent AF were randomly assigned to 2 different ablation schemes: pulmonary vein isolation (PVI) and PVI plus left linear lesions (LL). Primary end point was to assess the maintenance of sinus rhythm (SR) after procedures 1 and 2 in the absence of antiarrhythmic drugs in a long-term follow-up of at least 3 years. Paroxysmal AF- With a single procedure at 12-month follow-up, 46% of patients treated with PVI maintained SR, whereas at 3-year follow-up, 29% were in SR; using the "PVI plus LL" at the 12-month follow-up, 57% of patients were in SR, whereas at the 3-year follow-up, 53% remained in SR. After a second procedure, the long-term overall success rate without antiarrhythmic drugs was 62% with PVI and 85% with PVI plus LL. Persistent/Permanent AF- With a single procedure at the 12-month follow-up, ...
Giornale italiano di cardiologia (2006), 2009
Atrial fibrillation (AF) is the most frequent supraventricular arrhythmia. It is associated with ... more Atrial fibrillation (AF) is the most frequent supraventricular arrhythmia. It is associated with increased morbidity and mortality but its management is still under debate. The limited success of drug treatment has stimulated an exploration of interventional treatment options. Therefore, in the past decade, various ablative procedures, both surgical and transcatheter, have been proposed. Catheter ablation has involved mainly patients without structural heart disease. In the series published to date the percentage of patients with structural heart disease undergoing catheter ablation for AF is about 20%. These patients would benefit the most from the maintenance of sinus rhythm but on the other hand data show a higher post-procedural recurrence rate. In patients with valvular heart disease and indication to surgical repair or valvular replacement, surgical ablation is indicated in the majority of cases. Catheter ablation in patients with heart failure and AF should be considered when...
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, 2014
Atrial tachycardias are common after repair of atrial septal defect (ASD). Although ablation has ... more Atrial tachycardias are common after repair of atrial septal defect (ASD). Although ablation has shown promising results in the short and mid-term follow-up, little data regarding the very long-term success exist. Our aim was to assess very long-term follow-up in patients who have undergone electroanatomic-guided radiofrequency (RF) ablation of late-onset atrial arrhythmias after ASD surgery. Forty-six consecutive patients with surgically repaired ASD were referred for atrial tachycardia ablation. Electrophysiological (EP) study and ablation procedure with the aid of an electroanatomic mapping (EAM) system were performed. Mean age was 49 ± 13 years (females 61%). The presenting arrhythmias were typical atrial flutter (48%), atypical atrial flutter (35%), and atrial tachycardia (17%). In 41% of patients, atrial fibrillation was also present. The EP study showed a right atrial macroreentrant circuit in all the patients. In 12 of 46 (26%), the circuit was localized in the cavo-tricuspi...
Italian heart journal : official journal of the Italian Federation of Cardiology, 2002
This study investigated whether a minimal approach to typical atrial flutter ablation using an 8 ... more This study investigated whether a minimal approach to typical atrial flutter ablation using an 8 mm tip catheter with a 150 W generator with only the documentation of clockwise block by means of local criteria predicts a good long-term outcome. Seventy patients underwent typical atrial flutter ablation. A multipolar catheter was inserted into the coronary sinus (CS) and an 8 mm tip ablation catheter was used to ablate and map the isthmus. The ablation line was performed in the posteroseptal region. The clockwise block was confirmed by recording a corridor of double potentials along the line and by counterclockwise activation of the portion of the isthmus just beyond the lesion line as demonstrated by measuring the conduction times during CS pacing. In case of block, the mean distance between the two split atrial electrograms was 129 +/- 31 ms. Acute isthmus block was achieved in all 70 patients. The median of the radiofrequency pulses was 10 (range 1-36). No immediate or late compli...
Pacing and Clinical Electrophysiology, 2015
Background. Fluoroscopic catheter ablation of cardiac arrhythmias in pediatric patients exposes t... more Background. Fluoroscopic catheter ablation of cardiac arrhythmias in pediatric patients exposes the patients to the potential risk of radiation considering the sensitivity of this population and its longer life expectancy. We evaluated the feasibility, safety and efficacy of accessory pathway (AP) ablation guided by CARTO3 electroanatomic mapping (EAM) system with both cryoenergy and radiofrequency (RF) energy in order to avoid x-ray exposure in pediatric patients.
International Journal of Cardiac Imaging, 2000
should read:
Global Cardiology Science and Practice, 2013
CLINICAL CASE This is a case of a 50-year-old woman complaining of easy fatigability, anorexia an... more CLINICAL CASE This is a case of a 50-year-old woman complaining of easy fatigability, anorexia and hypotension since 2009. She also reported alopecia, a 15 kg weight loss, and amenorrhea. A year after the beginning of the symptoms she sought medical attention: a diagnosis of nephrotic syndrome with proteinuria . 10 g/L was made. A renal biopsy showed focal segmental glomerulosclerosis. Steroids and cyclosporin were then started. The patient did quite well until November 2011 when she was hospitalized for the recurrence of the symptoms. Because of persistent hypotension, Rituximab therapy instead of Bortezumib was instituted. At that time the ECG showed sinus rhythm with low QRS voltages and Q waves in the inferior leads and from V1 to V4. An echocardiogram showed severe symmetric left ventricular hypertrophy (21 mm of the interventricular septum and 20 mm of the posterior wall diastolic thickness). The left ventricular walls showed an inhomogeneous granular pattern. During systole, a virtual left ventricular cavity was evident with a left ventricular ejection fraction (LVEF) around 60%. A severe dynamic left ventricular outflow tract (LVOT) obstruction was present with a left ventricularaortic gradient of 120 mmHg at rest and 250 mmHg during the Valsalva maneuver. Moderate mitral regurgitation with a systolic anterior motion (SAM) of the mitral valve was demonstrated. Severe diastolic dysfunction was present, with an E/E' ratio of 12.3 cm/s ( ).
Journal of Cardiovascular Electrophysiology, 2014
Background: Simultaneous multipolar ablation catheters have been proposed to simplify pulmonary v... more Background: Simultaneous multipolar ablation catheters have been proposed to simplify pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (AF). Recently, a new multipolar irrigated radiofrequency (RF) ablation catheter (nMARQ TM , Biosense Webster Inc, Diamond Bar, California) combining both three-dimensional electroanatomic mapping and multipolar open-irrigated ablation capability has been developed. Aim of our study was to assess feasibility, acute and short-term success and safety of PVI by the use of this new technology with particular regard to the incidence of post-ablation silent cerebral ischemia (SCI).
Journal of Cardiovascular Medicine, 2010
To assess retrospectively clinical and procedural predictors of long-term recurrences after atria... more To assess retrospectively clinical and procedural predictors of long-term recurrences after atrial fibrillation ablation. Two hundred and forty consecutive patients (201 men; mean age 60 +/- 10 years) undergoing pulmonary vein isolation (PVI) plus linear lesion ablation for antiarrhythmic drug-refractory atrial fibrillation between 2005 and 2007 were studied. Magnetic resonance imaging of the left atrium was performed in all the patients. Patients were followed up with clinical examination and ECG Holter at 1, 3, 6 months and every 6 months thereafter. In case of recurrence, a second procedure was offered. Clinical and procedural data were evaluated with univariate and multivariate analysis. At a mean follow-up of 30.3 +/- 9.2 months after one or two procedures, 99 (41.3%) patients were in sinus rhythm without antiarrhythmic drugs and 50 patients (20.8%) had arrhythmia recurrences. These groups were compared in order to identify the clinical predictors of recurrences. Variables directly related to failure at univariate analysis were: history of persistent atrial fibrillation, number of previous electrical cardioversions, left atrial volume (LAV) at MRI, presence of pulmonary vein anatomical variants and BMI. At multivariate analysis, only left atrial volume measured at MRI was an independent predictor of failure. With long-term follow-up, LAV at MRI represents the main determinant of outcome after PVI plus linear lesion for ablation of paroxysmal and persistent atrial fibrillation.
Pacing and Clinical Electrophysiology, 2013
Anatomical considerations and risks related to x-ray exposure make atrioventricular nodal reentra... more Anatomical considerations and risks related to x-ray exposure make atrioventricular nodal reentrant tachycardia (AVNRT) ablation in pediatric patients a concerning procedure. We aimed to evaluate the feasibility, safety, and efficacy of performing fluoroless slow-pathway cryoablation guided by the electroanatomic (EA) mapping in children and adolescents. Twenty-one consecutive patients (mean age 13.5 ± 2.4 years) symptomatic for AVNRT were prospectively enrolled to right atrium EA mapping and electrophysiological study prior to cryoablation. Cryoablation was guided by slow-pathway potential and performed using a 4-mm-tip catheter. Sustained slow-fast AVNRT was inducible in all the patients with a dual AV nodal physiology in 95%. Acute success was achieved in 100% of the patients with a median of two cryo-applications. Fluoroless ablation was feasible in 19 patients, while in two subjects 50 seconds and 45 seconds of x-ray were needed due to difficult progression of the catheters along the venous system. After a mean follow-up of 25 months, AVNRT recurred in five patients. All the recurrences were successfully treated with a second procedure. In three patients, a fluoroless cryoablation with a 6-mm-tip catheter was successfully performed, while in the remaining two patients, a single pulse of 60 seconds of radiofrequency energy was applied under fluoroscopic monitoring. No complications occurred. Combination of EA mapping systems and cryoablation may allow to perform fluoroless slow-pathway ablation for AVNRT in children and adolescents in the majority of patients. Fluoroless slow-pathway cryoablation showed a high efficacy and safety comparable to conventional fluoroscopy guided procedures.
Journal of the American College of Cardiology, 2001
We aimed to evaluate: 1) the behavior of electrical activity simultaneously in different atrial r... more We aimed to evaluate: 1) the behavior of electrical activity simultaneously in different atrial regions during atrial fibrillation (AF); 2) the difference of atrial activation between paroxysmal and chronic AF; 3) the atrial refractoriness dispersion; and 4) the correlation between the effective refractory periods (ERPs) and the FF intervals. BACKGROUND Little data exist on the electrophysiologic characteristics of the different atrial regions in patients with AF. A more detailed knowledge of the electrical activity during AF may provide further insights to improve treatment of AF.
Journal of the American College of Cardiology, 2001
Journal of the American College of Cardiology, 2000
We sought to evaluate whether a limited surgical cryoablation of the posterior region of the left... more We sought to evaluate whether a limited surgical cryoablation of the posterior region of the left atrium was safe and effective in the cure of atrial fibrillation (AF) in patients with associated valvular heart disease. BACKGROUND Extensive surgical ablation of AF is a complex and risky procedure. The posterior region of the left atrium seems to be important in the initiation and maintenance of AF.
Journal of Cardiovascular Electrophysiology, 2000
Atrial Flutter Mapping. Introduction: The aim of this study was to map the low right atrium befor... more Atrial Flutter Mapping. Introduction: The aim of this study was to map the low right atrium before and after radiofrequency ablation of the inferior vena tava-tricuspid annulus (IVC-TA) isthmus in patients with typical atrial flutter (AFI) to better understand the electrophysiologic meaning of incomplete or unidirectional block following the ahlation procedure and its relationship with AFI recurrence.
Journal of Cardiovascular Electrophysiology, 2012
Catheter Design and Anticoagulation on Postablation Silent Cerebral Ischemia. Introduction: Silen... more Catheter Design and Anticoagulation on Postablation Silent Cerebral Ischemia. Introduction: Silent cerebral lesions (SCL) are a sensitive tool to evaluate thromboembolic risk of catheter ablation. Recent data showed the possibility to reduce thrombus formation when the electrode-tissue interface cooling is optimized by a homogeneous flushing of saline along the entire surface of the distal electrode through a larger number of irrigation holes. The study aim is to compare procedural parameters and safety of pulmonary vein isolation (PVI) performed by using open-irrigated catheters with different irrigation design.
International Journal of Cardiology, 2013
Background: The 12-lead electrocardiogram (ECG) is considered an essential screening tool for hyp... more Background: The 12-lead electrocardiogram (ECG) is considered an essential screening tool for hypertrophic cardiomyopathy (HCM). A vast array of ECG abnormalities has been described in HCM, although their relationship to left ventricle (LV) morphology and degree of hypertrophy appears elusive. Aim of this study was to assess the relationship of ECG patterns with the HCM phenotype assessed according to the novel opportunities offered by cardiac magnetic imaging (CMR). Methods: CMR and 12-lead ECG were performed in 257 HCM patients. Severity of ECG abnormalities was defined by the sum of 9 criteria: abnormal cardiac rhythm, QRS duration ≥ 100 ms, Romhilt-Estes score ≥ 5, fascicular block (LAHB) and/or bundle-branch block (LBBB or RBBB), ST-T abnormalities, ST-T segment elevation ≥ 0.2 mV, prolonged QTc interval, pathological Q waves, absence of normal Q wave. Four ECG groups were identified: normal (0 criteria); mildly abnormal (1-3 criteria); moderately abnormal (4-6 criteria); markedly abnormal (7-9 criteria). Results: There was a direct relationship between severity of ECG abnormalities and HCM phenotype. LV mass index was normal in most patients with normal ECG and progressively increased with each class of ECG score, from 70.9 ± 18.6 g/m 2 in patients with normal ECG to 107.1 ± 55.1 g/m 2 among those with markedly abnormal ECG (p = b 0.0001). Likewise, the prevalence and extent of late gadolinium enhancement (LGE) increased significantly with the ECG score, from 37% in patients with normal ECG to 93% in patients with markedly abnormal ECG (overall p = 0.0012). A normal ECG had a negative predictive accuracy of 96% for markedly increased LV mass (> 91 g/m 2 for men and >69 g/m 2 for women), and of 100% for maximum LV thickness ≥ 30 mm. Conclusions: In a large HCM cohort, the number and severity of ECG abnormalities were directly related to phenotypic expression as revealed by CMR. Although false negative ECG findings remain a challenge in population screenings for HCM, a normal ECG proved effective in ruling out severe LV hypertrophy, suggesting potential implications for long-term follow-up of HCM patients and family members. A simple score for quantification of ECG abnormalities in HCM patients is proposed.
Europace, 2010
In patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF), radiofrequency c... more In patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF), radiofrequency catheter ablation (RFCA) represents a promising option. However, the predictors of RFCA efficacy remain largely unknown. We assessed the outcome of a multicentre HCM cohort following RFCA for symptomatic AF refractory to medical therapy. Sixty-one patients (age 54 +/- 13 years; time from AF onset 5.7 +/- 5.5 years) with paroxysmal (n = 35; 57%), recent persistent (n = 15; 25%), or long-standing persistent AF (n = 11; 18%) were enrolled. A scheme with pulmonary vein isolation plus linear lesions was employed. Of the 61 patients, 32 (52%) required redo procedures. Antiarrhythmic therapy was maintained in 22 (54%). At the end of a 29 +/- 16 months follow-up, 41 patients (67%) were in sinus rhythm, including 17 of the 19 patients aged < or = 50 years, with marked improvement in New York Heart Association (NYHA) functional class (1.2 +/- 0.5 vs. 1.9 +/- 0.7 at baseline; P < 0.001). In the remaining 20 patients (33%), with AF recurrence, there was less marked, but still significant, improvement following RFCA (NYHA class 1.8 +/- 0.7 vs. 2.3 +/- 0.7 at baseline; P = 0.002). Independent predictors of AF recurrence were increased left atrium volume [hazard ratio (HR) per unit increase 1.009, 95% confidence interval (CI) 1.001-1.018; P = 0.037] and NYHA functional class (HR 2.24, 95% CI 1.16-4.35; P = 0.016). Among 11 genotyped HCM patients (6 with MYBPC3, 2 with MYH7, 1 with MYL2 and 2 with multiple mutations), RFCA success rate was comparable with that of the overall cohort (n = 8; 73%). RFCA was successful in restoring long-term sinus rhythm and improving symptomatic status in most HCM patients with refractory AF, including the subset with proven sarcomere gene mutations, although redo procedures were often necessary. Younger HCM patients with small atrial size and mild symptoms proved to be the best RFCA candidates, likely due to lesser degrees of atrial remodelling.
Europace, 2011
Atrial fibrillation (AF) ablation still requires long procedural time and high radiation exposure... more Atrial fibrillation (AF) ablation still requires long procedural time and high radiation exposure with its related risk for the patient and the operators. This study was designed to compare three different approaches of AF ablation to verify the hypothesis that image integration with electroanatomic mapping allows minimal use of fluoroscopy. Therefore, we evaluated the procedure and fluoroscopy times of ablation using three imaging modalities: conventional fluoroscopy, image integration electroanatomic mapping, and a new electroanatomic mapping system that provides visualization of multiple catheters. One hundred and twenty patients with symptomatic refractory AF were enrolled in the study. Patients were randomly assigned to fluoroscopy alone (Group A, 40 patients), electroanatomic integration (Cartomerge®, Group B, 40 patients), and electroanatomic integration plus catheters visualization (Carto® 3 System, Group C, 40 patients) guided procedures. The ablation procedure aimed at isolating the pulmonary veins and creating lesion lines at the left atrial roof and left isthmus. Procedure and fluoroscopy parameters were recorded in all patients. Total procedure time and skin to catheter positioning time did not significantly differ between the groups. Total fluoroscopy time was statistically different between all three groups (Group A, 18'09″±5'00″; Group B, 9'48″±3'41″; Group C, 2'28″±1'40″; P<0.001). A significant difference was noted in ablation fluoroscopy time between all groups (P<0.001), mainly due to shortened fluoroscopy time in Group B (7'34″±3'15″) and Group C (0'21″±0'31″) when compared with Group A (16'07″±5'04″). Image integration and, to a larger extent, visualization of multiple catheters allowed a minimal use of fluoroscopy in transcatheter AF ablation.
Europace, 2004
Aims To verify if sites of conduction gaps on the isthmus correlate with anatomical peculiarities... more Aims To verify if sites of conduction gaps on the isthmus correlate with anatomical peculiarities using the intracardiac echo (ICE) and a new 3D device to reconstruct the isthmus in patients undergoing cavotricuspid isthmus ablation. Methods and results Twenty patients underwent isthmus ablation using an 8 mm tip ablation catheter. Two-dimensional and 3D ICE reconstruction of the isthmus was made before, during and after ablation. At the end of the lesion line isthmus block was validated by electrophysiological criteria. In case of its absence we closed the remaining conduction gaps verifying the position of the sites with ICE. Fourteen patients required a median of 8 RF pulses to obtain complete isthmus block (Group A). In the remaining 6 patients isthmus block was obtained with a median of 25 RF pulses due to conduction gaps 'resistant' to ablation (Group B). Conduction gap positions assessed by ICE were located in the central portion of the isthmus below the coronary sinus os in 71% of cases in Group A and along a prominent Eustachian ridge in Group B patients, respectively. 3D reconstruction showed a smooth isthmus in Group A with a 'peak and valleys' isthmus in Group B. In these latter patients isthmus block was obtained only after the complete ablation of the prominent Eustachian ridge. Conclusion The isthmus presents anatomical variants particularly due to Eustachian ridge peculiarities which may represent a site of conduction gaps ''resistant'' to ablation.