JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 11 2008
DAVID M. LURIA M.D.
Introduction: Patients with atrial flutter (AFL) treated medically are at high risk for subsequent development of atrial fibrillation (AF). Whether curative radiofrequency ablation of AFL can modify the natural history of arrhythmia progression is not clear. We aimed to determine whether ablation of AFL decreases the subsequent development of AF in patients without previous AF. Methods and Results: Patients with AFL as the sole atrial arrhythmia were selected from patients who underwent successful AFL ablation at Mayo Clinic between 1997 and 2003 (N = 137). The cohort was divided by presence (n = 50) or absence (n = 87) of structural heart disease. A control group comprised 59 patients with AFL and no history of paroxysmal AF, who received only medical therapy. Occurrence of AF after AFL ablation was compared among study groups and controls. Symptomatic AF occurred in 49 patients during 5 years of follow-up after AFL ablation, with similar frequency in both study groups. The cumulative probability of paroxysmal and chronic AF was similar in controls and each study group. By multivariate analysis, the AFL ablation procedure carries significant risk of AF occurrence during follow-up. Fifty patients discontinued antiarrhythmic drugs after AFL ablation, and the rate of cardioversions decreased. Conclusion: Successful ablation of AFL does not improve the natural history of atrial arrhythmia progression; postablation AF is frequent. This suggests that AFL may be initiated by bursts of AF and that in the absence of AFL substrate the AF continues to progress. [source]

Prednisone Prevents Inducible Atrial Flutter in the Canine Sterile Pericarditis Model

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 1 2008
ROBERT N. GOLDSTEIN M.D.
Background: Atrial fibrillation (AF) and atrial flutter (AFL) are common following cardiac surgery and are associated with significant morbidity. We tested the hypothesis that suppression of the inflammatory response with steroids would significantly modify the inducibility of postoperative AF/AFL in the canine sterile pericarditis model. Methods: Twenty-three dogs were studied daily from creation of pericarditis to the fourth postoperative day: 11 dogs were treated with oral prednisone (PRED) starting 2 days preoperatively until the end of the study; 12 dogs were controls (CON). EP testing was performed daily using epicardial electrodes placed at initial surgery. High-resolution (404 sites) epicardial mapping was performed during the terminal study. Baseline and daily CRP levels were obtained in all dogs. Results: Sustained AFL was absent in PRED (0%) versus CON dogs (91%; P < 0.001); AF induced in the early postoperative course in PRED dogs was of very short CL (mean 66 ms). Tissue inflammation was significantly attenuated in PRED dogs. Thresholds were lower in PRED versus CON dogs, significantly so on postoperative day (POD) 3. There was a trend toward lower ERPs in the PRED group at all CLs. CRP levels were markedly reduced in PRED versus CON dogs (peak CRP 78 ± 7 mg/L vs 231 ± 21 mg/L, P < 0.001), and returned to baseline in PRED dogs by POD 4, correlating with a virtual absence of sustained arrhythmia. During open chest mapping studies on POD 4, PRED dogs showed only nonsustained AF/AFL. Conclusions: Prednisone eliminated postoperative AFL, affected all EP parameters studied, and attenuated the inflammatory response associated with pericarditis. [source]

Incidence of Atrial Fibrillation Post-Cavotricuspid Isthmus Ablation in Patients with Typical Atrial Flutter: Left-Atrial Size as an Independent Predictor of Atrial Fibrillation Recurrence

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 8 2007
KEITH ELLIS M.D.
Introduction: Atrial fibrillation and atrial flutter often coexist. The long-term occurrence of atrial fibrillation in patients presenting with atrial flutter alone is unknown. We report the long-term follow-up in patients who underwent cavotricuspid isthmus ablation for treatment of lone atrial flutter. Methods and Results: Between January 1997 and June 2002, 632 patients underwent cavotricuspid isthmus ablation for the treatment of typical atrial flutter at the Cleveland Clinic Foundation. Three hundred sixty-three patients were included in this study and followed for a mean duration of 39 ± 11 months. The mean duration of atrial flutter symptoms was 12 ± 5 months. Mean left-atrial size and left-ventricular ejection fraction were 4.2 ± 0.8 cm and 47 ± 13%, respectively. After a mean follow-up time of 39 ± 11 months, 13% (48 of 363) of the patients remained in sinus rhythm. Five percent (18 of 363) of patients experienced recurrence of atrial flutter only. Sixty-eight percent (246 of 363) experienced the onset of atrial fibrillation and 14% (51 of 363) experienced recurrence of atrial flutter and the new onset of atrial fibrillation. Overall, 82% (297 of 363) of the patients experienced new onset of drug refractory atrial fibrillation. Left-atrial size was a predictor of atrial fibrillation recurrence post-atrial flutter ablation. Conclusion: At long-term follow-up, approximately 82% of patients post-cavotricuspid isthmus ablation for atrial flutter developed drug refractory atrial fibrillation. This finding suggests that elimination of atrial flutter might delay, but does not prevent, atrial fibrillation. Evidence suggests both arrhythmias may share common triggers and such patients may derive a better long-term benefit from anatomical ablative treatment of atrial fibrillation as well. [source]

Surface Electrocardiographic Patterns and Electrophysiologic Characteristics of Atrial Flutter Following Modified Radiofrequency MAZE Procedures

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2007
JOSEPH G. AKAR M.D., Ph.D.
Introduction: The radiofrequency MAZE is becoming a common adjunct to cardiac surgery in patients with atrial fibrillation. While a variety of postoperative arrhythmias have been described following the original Cox-MAZE III procedure, the electrophysiological characteristics and surgical substrate of post-radiofrequency MAZE flutter have not been correlated. We sought to determine the location, ECG patterns, and electrophysiological characteristics of post-radiofrequency MAZE atrial flutter. Methods: Nine consecutive patients with post-radiofrequency MAZE flutter presented for catheter ablation 9 ± 10 months after surgery. Results: Only one patient (11%) had an ECG appearance consistent with typical isthmus-dependent right atrial (RA) flutter. However, on electrophysiological study, 3/9 patients (33%) had typical right counter-clockwise flutter entrained from the cavo-tricuspid isthmus, despite description of surgical isthmus ablation. Six patients (67%) had left atrial (LA) circuits. These involved the mitral annulus in 5/6 cases (83%) despite description of surgical mitral isthmus ablation in the majority (60%). LA flutters had a shorter cycle length compared with RA flutters (253 ± 39 msec and 332 ± 63 msec respectively, P < 0.05). After a mean of 8 ± 4 months following ablation, 8/9 patients (89%) were in sinus rhythm. Conclusion: Up to one-third of post-radiofrequency MAZE circuits are typical isthmus-dependent RA flutters, despite a highly atypical surface ECG morphology. Therefore, diagnostic electrophysiological studies should commence with entrainment at the cavo-tricuspid isthmus in order to exclude typical flutter, regardless of the surface ECG appearance. Incomplete surgical lesions at the mitral and cavo-tricuspid isthmus likely predispose to the development of post-radiofrequency MAZE flutter. [source]

Simultaneous Atrial and Ventricular Anti-Tachycardia Pacing as a Novel Method of Rhythm Discrimination

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 7 2006
SAMIR SABA M.D.
Background: Inappropriate shocks remain a problem in patients with defibrillators (ICD). Objective: To evaluate a new discrimination algorithm for supraventricular (SVT) and ventricular (VT) tachycardias, based on the response to simultaneous (A+V) atrial (A) and ventricular (V) anti-tachycardia pacing (ATP). Methods: Patients undergoing electrophysiological testing or dual-chamber implantable cardioverter-defibrillator (ICD) implantation were enrolled (N = 32) and underwent A+V ATP through a Marquis ICD with investigational software. If persisting after ATP, the rhythm was classified as VT if the first electrical event was sensed on the V channel and as an SVT otherwise. Results: Arrhythmia sequences (N = 275; 53 VT; 222 SVT) were analyzed in 26 patients (age = 51 ± 17 years, 13 men, LVEF = 0.49 ± 0.14). In response to A+V ATP, 55% of SVT versus 41% of VT episodes were terminated (P = NS). Termination of VT but not of SVT was more likely with faster (50% at ATP/arrhythmia cycle length (CL) = 0.81 vs 8% at ATP/arrhythmia CL = 0.88, P = 0.02) but not with longer ATP bursts (P = NS). Of the 115 arrhythmias that persisted after A+V ATP, the algorithm correctly classified 24 of 24 VT (GEE-adjusted sensitivity = 100%) and 85 of 91 SVT (GEE-adjusted specificity = 93%). Proarrhythmia was noted after two A+V ATP, in the form of atrial fibrillation induction and VT acceleration. Conclusions: We describe a new algorithm that can discriminate between SVT and VT with a high sensitivity and specificity. This form of ATP can terminate 55% of SVT sequences. The performance of this new algorithm merits further testing in a large population of dual-chamber ICD patients. [source]

Multicenter, Prospective, Randomized Safety and Efficacy Study of a New Atrial-Based Managed Ventricular Pacing Mode (MVP) in Dual Chamber ICDs

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 8 2005
MICHAEL O. SWEENEY M.D.
Background: Ventricular desynchronization caused by right ventricular pacing may impair ventricular function and increase risk of heart failure (CHF), atrial fibrillation (AF), and death. Conventional DDD/R mode often results in high cumulative percentage ventricular pacing (Cum%VP). We hypothesized that a new managed ventricular pacing mode (MVP) would safely provide AAI/R pacing with ventricular monitoring and DDD/R during AV block (AVB) and reduce Cum%VP compared to DDD/R. Methods: MVP RAMware was downloaded in 181 patients with Marquis DR ICDs. Patients were initially randomized to either MVP or DDD/R for 1 month, then crossed over to the opposite mode for 1 month. ICD diagnostics were analyzed for cumulative percentage atrial pacing (Cum%AP), Cum%VP, and duration of DDD/R pacing for spontaneous AVB. Results: Baseline characteristics included age 66 ± 12 years, EF 36 ± 14%, and NYHA Class II,III 36%. Baseline PR interval was 190 ± 53 msec and programmed AV intervals (DDD/R) were 216 ± 50 (paced)/189 ± 53 (sensed) msec. Mean Cum%VP was significantly lower in MVP versus DDD/R (4.1 ± 16.3 vs 73.8 ± 32.5, P < 0.0001). The median absolute and relative reductions in Cum%VP during MVP were 85.0 and 99.9, respectively. Mean Cum%AP was not different between MVP versus DDD/R (48.7 ± 38.5 vs 47.3 ± 38.4, P = 0.83). During MVP overall time spent in AAI/R was 89.6% (intrinsic conduction), DDD/R 6.7% (intermittent AVB), and DDI/R 3.7% (AF). No adverse events were attributed to MVP. Conclusions: MVP safely achieves functional atrial pacing by limiting ventricular pacing to periods of intermittent AVB and AF in ICD patients, significantly reducing Cum%VP compared to DDD/R. MVP is a universal pacing mode that adapts to AVB and AF, providing both atrial pacing and ventricular pacing support when needed. [source]

Iatrogenic Postatrial Fibrillation Ablation Left Atrial Tachycardia/Flutter: How to Prevent and Treat It?

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 3 2005
ANTONIO RAVIELE M.D.
First page of article [source]

Mechanism of Propensity to Atrial Fibrillation in Patients Undergoing Isthmus Ablation for Typical Atrial Flutter

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 2 2005
HEMANTH RAMANNA M.D.
Background: Patients undergoing isthmus ablation for atrial flutter (AFL) may reveal postablation atrial fibrillation (AF). The electrophysiological mechanism is unclear. In patients with idiopathic AF, enhanced spatial dispersion of right atrial refractoriness was the substrate for the initiation of AF. We hypothesize that dispersion of right atrial refractoriness in patients undergoing AFL ablation is the major cause of postablation AF. Methods: Consecutive patients (n = 42) undergoing isthmus ablation for typical AFL were included. Twelve right atrial unipolar electrograms were recorded. Inducibility of AF was assessed by a pacing protocol, starting with one extrastimulus, followed by more aggressive pacing until AF was induced. Mean fibrillatory intervals were used to assess local refractoriness of each recording site. Spatial dispersion of right atrial refractoriness was calculated as the coefficient of dispersion (CD-value: standard deviation of the mean of all local mean fibrillatory intervals as a percentage of the overall mean fibrillatory interval). A CD-value of 3.0 or less was defined as normal, whereas CD-value greater than 3.0 was considered enhanced dispersion. PES and refractoriness analysis were followed by isthmus ablation. Results: Of the 42 patients, 29 had CD-value of 3.0 or less. In these 29 patients, AF was induced with 1 extrastimulus in only 1 patient, with 2 extrastimuli in 4 patients and burst pacing was required to induce AF in 24 of these 29 patients. Prior to the procedure, 5 of 29 patients had AF episodes, after ablation 6 of 29 patients. Of the 42 patients, 13 had CD-value greater than 3.0, AF was induced with a single extrastimulus in 11 patients, with 2 extrastimuli in the remaining 2 patients. Of the 13 patients, 11 had AF episodes both before and after ablation (P < 0.001). Conclusion: Enhanced spatial dispersion of right atrial refractoriness may be the substrate for propensity to AF in patients with AFL. The substrate was associated with enhanced inducibility of atrial fibrillation. [source]

Effect of Chronic Amiodarone Therapy on Excitable Gap During Typical Human Atrial Flutter

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 12 2004
PHILIPPE MAURY M.D.
Introduction: Class I antiarrhythmic drugs increase duration of the excitable gap (EG) during typical atrial flutter whereas intravenous class III drugs decrease the EG. The effect of chronic oral amiodarone therapy on the EG is unknown. Methods and Results: EG was prospectively determined by introducing a premature stimulus and analyzing the response pattern during typical atrial flutter in 30 patients without antiarrhythmic drugs and in 20 patients under chronic oral amiodarone therapy. EG was calculated by the difference between the longest coupling interval leading to resetting and the effective atrial refractory period (EARP). A fully EG was defined by the portion of EG where the response curve of the return cycles was flat. A partially EG was defined by the portion of EG where the return cycle increases while coupling interval decreases. A resetting response curve was constructed by plotting the duration of the return cycle against the value of the coupling interval. Cycle length (CL; 222 ± 17 vs 267 ± 20 msec, P < 0.0001), EARP (128 ± 16 vs 152 ± 18 msec, P < 0.0001), and EG (54 ± 19 vs 70 ± 21 msec, P = 0.01) were significantly longer in patients taking amiodarone than in controls. Compared to CL, the relative part of the EARP (57 ± 7 vs 57 ± 6%, P = 0.96) and EG (24 ± 7 vs 26 ± 8%, P = 0.41) were comparable in both groups. The fully EG was larger in patients under chronic amiodarone therapy than in controls (39 ± 21 vs 26 ± 20 msec, P = 0.03). Neither duration of the partially EG (28 ± 15 vs 31 ± 15 msec, P = 0.42) nor slope of the ascending portion of the resetting response curve (1.15 ± 0.5 vs 1.13 ± 0.4 msec/msec, P = 0.71) differed between the two groups. Conclusion: EG in patients under chronic amiodarone therapy is significantly larger than in controls, mainly because of a longer fully EG. This observation may be explained by opposite effects on conduction velocity and refractoriness. [source]

Catheter Ablation of Common-Type Atrial Flutter Guided by Three-Dimensional Right Atrial Geometry Reconstruction and Catheter Tracking Using Cutaneous Patches:

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 10 2004
A Randomized Prospective Study
Introduction: EnSite® NavXÔ (NavX) is a novel mapping and navigation system that allows visualization of conventional catheters for diagnostic and ablative purposes and uses them to create a three-dimensional (3D) geometry of the heart. NavX is particularly suitable for ablation procedures utilizing an anatomic approach, as in the setting of common-type atrial flutter (AFL). The aim of this study was to compare NavX-guided and conventional ablation procedures for AFL. Methods and Results: Forty consecutive patients (32 male, 59 ± 12 years) with documented AFL were randomized to undergo fluoroscopy-guided (group I, 20 patients) or NavX-guided (group II, 20 patients) ablation, including 3D isthmus reconstruction. The same catheter setup was used in both groups. The endpoint of bidirectional isthmus block was obtained in all patients. Compared to conventional approaches, NavX-guided procedures significantly reduced fluoroscopy time (5.1 ± 1.4 min vs 20 ± 11 min, P < 0.01) and total x-ray exposure (5.1 ± 3.1 Gycm2 vs 24.9 ± 1.6 Gycm2, P < 0.01). Isthmus geometry reconstruction could be performed in all patients of group II. In 4 patients (20%) of group II, anatomic isthmus variations were detected by NavX. No significant differences in radiofrequency current applications and procedural times were found between the two groups. Conclusion: NavX technology allows geometry reconstruction of the cavotricuspid isthmus. NavX-guided ablation of AFL reduces total x-ray exposure compared to the fluoroscopy-guided approach but does not prolong procedure time. [source]

Entrainment Mapping of Dual-Loop Macroreentry in Common Atrial Flutter:

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 6 2004
New Insights into the Atrial Flutter Circuit
Introduction: The aim of this study was to determine using entrainment mapping whether the reentrant circuit of common type atrial flutter (AFL) is single loop or dual loop. Methods and Results: In 12 consecutive patients with counterclockwise (CCW) AFL, entrainment mapping was performed with evaluation of atrial electrograms from the tricuspid annulus (TA) and the posterior right atrial (RA) area. We hypothesized that a dual-loop reentry could be surmised from "paradoxical delayed capture" of the proximal part of the circuit having a longer interval from the stimulus to the captured beat compared with the distal part of the circuit. In 6 of 12 patients with CCW AFL, during entrainment from the septal side of the posterior blocking line, the interval from the stimulus to the last captured beat was longer at the RA free wall than at the isthmus position. In these six patients with paradoxical delayed capture, flutter cycle length (FCL) was 227 ± 12 ms and postpacing interval minus FCL was significantly shorter at the posterior blocking line than at the RA free wall (20 ± 11 ms vs 48 ± 33 ms, P < 0.05). In two of these patients, early breakthrough occurred at the lateral TA. A posterior block line was confirmed in all six patients in the sinus venosa area by intracardiac echocardiography. Conclusion: Half of the patients with common type AFL had a dual-loop macroreentrant circuit consisting of an anterior loop (circuit around the TA) and a posterior loop (circuit around the inferior vena cava and the posterior blocking line). (J Cardiovasc Electrophysiol, Vol. 15, pp. 679-685, June 2004) [source]

Rapid Magnetic Electroanatomic Mapping of Typical Atrial Flutter Using a Novel Multielectrode Catheter

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 6 2003
Vijay S. Chauhan M.D. F.R.C.P.C.
[source]

Left Atrial Flutter After Radiofrequency Catheter Ablation of Focal Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2003
JULIÁN VILLACASTÍN M.D.
We report an arrhythmic complication in two patients in whom a procedure directed at isolating one or two pulmonary veins had been performed. The complication was related to pulmonary vein disconnection scars after ablation. Both patients developed new clinical tachycardia (atypical atrial flutter) secondary to a reentrant phenomena in the vicinity of a previously ablated pulmonary vein.(J Cardiovasc Electrophysiol, Vol. 14, pp. 417-421, April 2003) [source]

Electrogram Polarity and Cavotricuspid Isthmus Block During Ablation of Typical Atrial Flutter

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2001
HIROSHI TADA M.D.
Electrogram Polarity in Atrial Flutter Ablation.Introduction: The atrial activation sequence around the tricuspid annulus has been used to assess whether complete block has been achieved across the cavotricuspid isthmus during radiofrequency ablation of typical atrial flutter. However, sometimes the atrial activation sequence does not clearly establish the presence or absence of complete block. The purpose of this study was to determine whether a change in the polarity of atrial electrograms recorded near the ablation line is an accurate indicator of complete isthmus block. Methods and Results: Radiofrequency ablation was performed in 34 men and 10 women (age 60 ± 13 years [mean ± SD]) with isthmus-dependent, counterclockwise atrial flutter. Electrograms were recorded around the tricuspid annulus using a duodecapolar halo catheter. Electrograms recorded from two distal electrode pairs (E1 and E2) positioned just anterior to the ablation line were analyzed during atrial flutter and during coronary sinus pacing, before and after ablation. Complete isthmus block was verified by the presence of widely split double electrograms along the entire ablation line. Complete bidirectional isthmus block was achieved in 39 (89%) of 44 patients. Before ablation, the initial polarity of E1 and E2 was predominantly negative during atrial flutter and predominantly positive during coronary sinus pacing. During incomplete isthmus block, the electrogram polarity became reversed either only at E2, or at neither E1 nor E2. In every patient, the polarity of E1 and E2 became negative during coronary sinus pacing only after complete isthmus block was achieved. In 4 patients (10%), the atrial activation sequence recorded with the halo catheter was consistent with complete isthmus block, but the presence of incomplete block was accurately detected by inspection of the polarity of E1 and E2. Conclusion: Reversal of polarity in bipolar electrograms recorded just anterior to the line of isthmus block during coronary sinus pacing after ablation of atrial flutter is a simple, quick, and accurate indicator of complete isthmus block. [source]

Assessment of Complete Isthmus Block After Ablation of Typical Atrial Flutter: Can We Rely on a Single Criterion?

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2001
FRÉDÉRIC ANSELME M.D.
[source]

Typical Atrial Flutter Ablation: Conduction Across the Posterior Region of the Inferior Vena Cava Orifice May Mimic Unidirectional Isthmus Block

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2000
MARCO SCAGLIONE M.D.
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 cava-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 ablation procedure and its relationship with AFI recurrence. Methods and Results: We performed atrial mapping in 12 patients using a "basket" catheter in the IVC orifice, Halo catheter in the right atrium, and multipolar catheters in the coronary sinus (CS) and His region. In patients in sinus rhythm, atrial activation was analyzed during pacing from the CS and low lateral right atrium (KLRA) before and after ablation. Atrial activation propagated across the isthmus and posterior region of the IVC orifice simultaneously before ablation. Mapping during AFI in four patients showed that the crista terminalis was a site of functional block. After ablation, evaluation of Halo catheter recordings in three patients showed apparent unidirectional counterclockwise block, whereas analysis of basket catheter recordings demonstrated complete bidirectional block. The apparent conduction over the isthmus during pacing from proximal CS was due to conduction along the posterior part of the IVC orifice, which activated the LLRA despite complete isthmus block. Conclusion: Our results demonstrate that limited endocardial mapping may yield a pattern compatible with unidirectional block in the IVC-TA isthmus, although bidirectional block is present at this anatomic level. [source]

Ablation of Atypical Atrial Flutter Guided by the Use of Concealed Entrainment in Patients Without Prior Cardiac Surgery

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 2 2000
FRANK BOGUN M.D.
Ablation of Atypical Atrial Flutter. Introduction: Mapping techniques have not been systematically evaluated with respect to atypical atrial flutter (AF) not involving the inferior vena cava isthmus. The purpose of this study was to assess prospectively the use of concealed entrainment (CE) in mapping of AF and to assess the clinical benefit of ablation of clinically relevant atypical AF. Methods and Results: In seven consecutive patients without prior cardiac surgery presenting with atypical AF, mapping was performed in the right and, if necessary, left atrium. At sites with CE, radiofrequency energy was delivered. In a posthoc analysis, the endocardial activation time, stimulus-flutter wave (F) interval, presence of split potentials and diastolic potentials, and postpacing Interval were assessed, and effective sites were compared to ineffective sites. A total of 22 forms of atypical AE either could be induced or were present at the time of the study. Eleven of the 13 targeted atypical AFs (85%) were successfully ablated. The positive predictive value of CE increased from 45% to 75% in the presence of matching electrogram-F and stimulus-F intervals or if flutter terminated during entrainment pacing, and to 88% in the presence of split atrial electrograms or diastolic potentials. During short-term clinical follow-up, none of the patients had recurrence of the ablated AE. However, the majority of patients required either medication for atrial fibrillation or repeated interventions for new forms of AF. Conclusion: Mapping and ablation of atypical AF is feasible if sites with CE can be identified. However, the clinical benefit of successful ablations in patients with atypical flutter appears to be limited. [source]

Atrial, SA Nodal, and AV Nodal Electrophysiology in Standing Horses: Normal Findings and Electrophysiologic Effects of Quinidine and Diltiazem

JOURNAL OF VETERINARY INTERNAL MEDICINE, Issue 1 2007
Colin C. Schwarzwald
Background: Although atrial arrhythmias are clinically important in horses, atrial electrophysiology has been incompletely studied. Hypotheses: Standard electrophysiologic methods can be used to study drug effects in horses. Specifically, the effects of diltiazem on atrioventricular (AV) nodal conduction are rate-dependent and allow control of ventricular response rate during rapid atrial pacing in horses undergoing quinidine treatment. Animals: Fourteen healthy horses. Methods: Arterial blood pressure, surface electrocardiogram, and right atrial electrogram were recorded during sinus rhythm and during programmed electrical stimulation at baseline, after administration of quinidine gluconate (10 mg/kg IV over 30 minutes, n = 7; and 12 mg/kg IV over 5 minutes followed by 5 mg/kg/h constant rate infusion for the remaining duration of the study, n = 7), and after coadministration of diltiazem (0.125 mg/kg IV over 2 minutes repeated every 12 minutes to effect). Results: Quinidine significantly prolonged the atrial effective refractory period, shortened the functional refractory period (FRP) of the AV node, and increased the ventricular response rate during atrial pacing. Diltiazem increased the FRP, controlled ventricular rate in a rate-dependent manner, caused dose-dependent suppression of the sinoatrial node and produced a significant, but well tolerated decrease in blood pressure. Effective doses of diltiazem ranged from 0.125 to 1.125 mg/kg. Conclusions and Clinical Importance: Standard electrophysiologic techniques allow characterization of drug effects in standing horses. Diltiazem is effective for ventricular rate control in this pacing model of supraventricular tachycardia. The use of diltiazem for rate control in horses with atrial fibrillation merits further investigation. [source]

Ablation of Atrial Flutter in a Patient with a Tricuspid Valve Replacement after Endocarditis

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2009
PETER NORDBECK M.D.
Myocardial scars from heart surgery are a source of tachycardia, eventually causing late morbidity and sudden death. In general, catheter ablation has been shown to be an effective therapy for various rhythm disorders, but it has been rarely described after atrioventricular valve replacement. We report on a 45-year-old man who developed atrial flutter after implantation of a tricuspid valve bioprosthesis. An electrophysiological investigation revealed typical type-I counterclockwise atrial flutter that was successfully terminated by catheter ablation. A sinus rhythm was restored and remained stable during the course of treatment; the valvular function was not diminished. It is demonstrated that safe mapping and ablation of typical atrial flutter is possible after a tricuspid valve replacement. [source]

A Technique for the Rapid Diagnosis of Wide Complex Tachycardia with 1:1 AV Relationship in the Electrophysiology Laboratory

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 4 2009
AMIR ABDELWAHAB M.B. B.Ch., M.Sc.
Background:The differential diagnosis of wide complex tachycardia (WCT) with 1:1 atrioventricular (AV) relationship is broad. Accurate identification of the tachycardia mechanism is essential for successful ablation. We suggest a simple pacing maneuver that can immediately clarify the tachycardia mechanism in the electrophysiology laboratory. Methods:Eight consecutive patients (four males, 32 ± 14 years) demonstrating stable sustained WCT with persistent 1:1 AV relationship during electrophysiologic testing were included in this study. During the tachycardia, atrial overdrive pacing was performed. The following responses were observed: (1) a change of the QRS morphology during atrial pacing and (2) the first return electrogram of the tachycardia, whether occurring in the atrium (AVA response) or in the ventricle (AVVA response). Results:Atrial overdrive pacing was successfully performed in all patients. It was associated with either a change or narrowing of the QRS in all ventricular tachycardia (VT) patients but not in supraventricular tachycardia (SVT) patients. All VT patients had an AVVA response upon cessation of atrial overdrive pacing as opposed to AVA response in SVT patients, P = 0.029. Conclusion:The response to atrial overdrive pacing during WCT with 1:1 AV relationship can rapidly diagnose or rule out VT as a mechanism of tachycardia. [source]

Overdrive Versus Conventional or Closed-Loop Rate Modulation Pacing in the Prevention of Atrial Tachyarrhythmias in Brady-Tachy Syndrome: On Behalf of the Burden II Study Group

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 11 2008
ANDREA PUGLISI M.D.
Background:Optimizing dual-chamber pacing to prevent recurrences of atrial tachyarrhythmias (AT) in sinus node dysfunction is still debated. Despite the large number of studies, efficacy of sophisticated preventive algorithms has never been proven. It is not clear whether this is due to imperfect study designs or to a substantial inefficacy of pacing therapies. Aim:To intraindividually compare AT burden between an atrial overdrive and two heart rate modulation approaches: a conventional accelerometric-sensor-based DDDR mode and a contractility-driven rate responsive closed loop (CLS) algorithm. Methods and Results:Four hundred fifty-one patients with Brady-Tachy syndrome (BTS), severe bradycardia, and a documented episode of atrial fibrillation were enrolled. One month after implant, each pacing therapy was activated for 3 months in random order. A simple log transformation was used to handle large and skew AT burden distributions. Estimates were adjusted for false-positive AT episodes and reported as geometric means (95% confidence interval). A significantly higher AT burden was observed during overdrive, 0.14% (0.09%, 0.23%) (adjusted, 0.12%[0.07%, 0.20%]). Both DDDR and CLS performed better: respectively, 0.11% (0.07%, 0.17%) (adjusted, 0.08%[0.05%, 0.14%]), 0.06% (0.03%, 0.09%) (adjusted, 0.04%[0.03%, 0.07%]). All the comparisons were statistically significant. During overdrive significantly more patients had AT episodes of duration between 1 minute and 1 hour. No significant differences were observed for longer episodes. Conclusions:Atrial overdrive showed the worst performance in terms of AT burden reduction and should not be preferred to heart rate modulation approaches that still have to be considered as a first-choice pacing mode in BTS. [source]

Effects of Continuous and Triggered Atrial Overdrive Pacing on Paroxysmal Atrial Fibrillation in Pacemaker Patients

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 8 2008
ANDREAS SCHUCHERT M.D.
Background: The aim of the study was to compare the effects of different pacing strategies to prevent paroxysmal atrial fibrillation (AF): triggered atrial overdrive pacing versus the combination of triggered and continuous overdrive pacing. Methods: Patients with an indication for dual-chamber pacing (Selection 9000, Prevent AF; Vitatron B.V., Arnhem, the Netherlands) and a history of paroxysmal AF were randomized to triggered atrial pacing (three pacing functions, "triggered group": PAC SuppressionÔ, Post-PAC ResponseÔ, and Post-Exercise ResponseÔ) or to the combination of continuous (Pace ConditioningÔ) and triggered atrial pacing (four pacing functions, "combined group"). After 3 months, there was a crossover to the other pacemaker setting. Results: In 171 enrolled patients, the median AF burden of the combined group was with 2.1% versus 0.1% in the triggered group (P = 0.014). Fewer AF episodes were observed in the triggered (median: 7) than in the combined group (median: 116; P = 0.016). The combined group had more frequent atrial pacing (median 97%) than the triggered group with 85% (P < 0.001), but ventricular pacing was not significantly different with 95% and 96% in the combined and triggered group, respectively. After the crossover, the AF burden increased in the triggered group to 0.3% and decreased in the combined group to 0.4%. Conclusions: Triggered atrial pacing functions alone resulted in a low AF burden. The additional activation of continuous atrial overdrive pacing increased the percentage of atrial pacing, but had no beneficial effects on the prevention of paroxysmal AF. [source]

Alcohol Intake is Significantly Associated with Atrial Flutter in Patients under 60 Years of Age and a Shorter Right Atrial Effective Refractory Period

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 3 2008
GREGORY M. MARCUS M.D.
Background: Although evidence suggests that alcohol is associated with atrial fibrillation (AF), the association between alcohol and atrial flutter (AFL) has not been examined. The mechanism connecting alcohol and atrial arrhythmias is unknown. Methods: Alcohol intake was determined in 195 consecutive patients with AF and AFL. Control subjects included patients with other supraventricular arrhythmias (n = 132) and healthy subjects (n = 54). Because of important competing risk factors for atrial arrhythmias in the elderly, stratification by age was performed. In a subset, atrial effective refractory periods (AERPs) were obtained from the high right atrium and proximal and distal coronary sinus. Results: AF and AFL patients were significantly more likely to be daily alcohol drinkers (27% vs 14% of controls, P = 0.001). In multivariable analysis, AFL patients , 60 years of age were significantly more likely to be daily drinkers than to drink no alcohol compared to controls (odds ratio 17, 95% confidence interval 1.6,192.0, P = 0.019). Progressively more frequent alcohol intake was significantly associated with a progressively greater odds of AFL in patients , 60 years of age (P = 0.045). Neither AF subjects of any age nor AFL subjects > 60 years of age exhibited significant associations with alcohol after multivariable adjustment. Right AERPs shortened significantly with increasing amounts of alcohol intake (P = 0.025), whereas left AERPs were not associated with alcohol intake. Conclusions: Alcohol intake is positively associated with AFL in younger patients. The mechanism may be related to a shortening of the right AERP. [source]

Three-Dimensional Mapping of Atypical Right Atrial Flutter Late after Chest Stabbing

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 3 2008
DANIEL STEVEN M.D.
We present the case of a female patient who previously underwent cardiac surgery for traumatic anterior right atrial perforation after a stabbing attack. Four years later the patient presented with right atrial common type flutter and isthmus ablation was performed subsequently. However, three years after isthmus ablation the patient was readmitted with atypical right atrial flutter. Electrophysiological study revealed persistent bidirectional isthmus block. Three-dimensional mapping (NavX, St. Jude Medical, St. Paul, MN, USA) demonstrated an incisional tachycardia with the critical isthmus at the border of the anterior area of scar in a close proximity to the superior tricuspid annulus. After ablation of this isthmus the patient was arrhythmia free after a follow-up of 9 months. This case illustrates that three-dimensional scar mapping may help to identify unusual isthmus sites that may be simultaneously responsible for both typical and atypical atrial flutter. [source]

Feasibility Of Temporary Biventricular Pacing In Patients With Reduced Left Ventricular Function After Coronary Artery Bypass Grafting

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 2007
FRANK EBERHARDT M.D.
Background and Methods: Biventricular pacing improves hemodynamics after weaning from cardiopulmonary bypass in patients with severely reduced left ventricular (LV) function undergoing coronary artery bypass grafting (CABG). We examined the feasibility of temporary biventricular pacing for 96 hours postoperatively. Unipolar epicardial wires were placed on the roof of the right atrium (RA), the right ventricular (RV) outflow tract, and the LV free lateral wall and connected to an external pacing device in 51 patients (mean LV ejection fraction 35 ± 4%). Pacing and sensing thresholds, lead survival and incidence of pacemaker dysfunction were determined. Results: Atrial and RV pacing thresholds increased significantly by the 4th postoperative day, from 1.6 ± 0.2 to 2.5 ± 0.3 V at 0.5 ms (P = 0.03) at the RA, 1.4 ± 0.3 V to 2.7 ± 0.4 mV (P = 0.01) at the RV, and 1.9 ± 0.6 V to 2.9 ± 0.7 mV (P = 0.3) at the LV, while sensing thresholds decreased from 2.0 ± 0.2 to 1.7 ± 0.2 mV (P = 0.18) at the RA, 7.2 ± 0.8 to 5.1 ± 0.7 mV (P = 0.05) at the RV, and 9.4 ± 1.3 to 5.5 ± 1.1 mV (P = 0.02) at the LV. The cumulative overall incidence of lead failure was 24% by the 4th postoperative day, and was similar at the RV and LV. We observed no ventricular proarrhythmia due to pacing or temporary pacemaker malfunction. Conclusions: Biventricular pacing after CABG using a standard external pacing system was feasible and safe. [source]

Mechanism of Atrial Flutter Occurring Late After Orthotopic Heart Transplantation with Atrio-atrial Anastomosis

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 5 2005
JOSEPH E. MARINE
Objective: We sought to better define the electrophysiologic mechanism of atrial flutter in patients after heart transplantation. Background: Atrial flutter is a recognized problem in the postcardiac transplant population. The electrophysiologic basis of atrial flutter in this patient population is not completely understood. Methods: Six patients with cardiac allografts and symptoms related to recurrent atrial flutter underwent diagnostic electrophysiologic study with electroanatomic mapping and radiofrequency catheter ablation. Comparison was made with a control nontransplant population of 11 patients with typical counterclockwise right atrial flutter. Results: In each case, mapping showed typical counterclockwise activation of the donor-derived portion of the right atrium, with concealed entrainment shown upon pacing in the cavotricuspid isthmus (CTI). The anastomotic suture line of the atrio-atrial anastomosis formed the posterior barrier of the reentrant circuit. Ablation of the electrically active, donor-derived portion of the CTI was sufficient to terminate atrial flutter and render it noninducible. Comparison with the control population showed that the electrically active portion of the CTI was significantly shorter in patients with transplant-associated flutter and that ablation was accomplished with the same or fewer radiofrequency lesions. Conclusions: Atrial flutter in cardiac transplant recipients is a form of typical counterclockwise, isthmus-dependent flutter in which the atrio-atrial anastomotic suture line forms the posterior barrier of the reentrant circuit. Ablation in the donor-derived portion of the CTI is sufficient to create bidirectional conduction block and eliminate this arrhythmia. Ablation or surgical division of the donor CTI at the time of transplantation could prevent this arrhythmia. [source]

An Approach to Measure Atrial and Ventricular Heart Rate Variability Using Pacemaker-Mediated Intracardiac Electrograms

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 12 2003
ANDREAS SCHUCHERT
Heart rate variability (HRV) measurements are usually performed from ventricular beat-to-beat intervals because of the difficulty to precisely locate the P wave fiducial point in surface ECG recordings. The aim of the study was to describe an approach to determine the atrial and ventricular HRV using pacemaker-mediated intracardiac electrograms. Twelve patients with the dual chamber pacemaker Logos were included. The atrial and ventricular intracardiac electrograms were transmitted with the high resolution telemetry channel of the pacemaker to an external recorder for 20 minutes while the patients were supine. During the measurements the patients were in sinus rhythm with intrinsic AV conduction. After computer assisted triggering of the atrial and ventricular events, the resultant intervals were used to calculate the standard deviation of all NN intervals (SDNN), the square root of the mean squared differences of successive NN intervals (RMSSD), and the percentage of successive interval differences >50 ms (pNN50). The differences between atrial and ventricular HRV-Indexes were assessed for each patient with a cut-off point of 1%. Differences >1% were analyzed in detail. A total of 15,504 heart cycles were analyzed. A manual correction due to false or not triggered atrial or ventricular events was necessary in 0.9%. The overall difference between atrial and ventricular pNN50 was ,0.5%±2.1%and differences >1% were observed in 4 patients. The NN50 events occurred in the atrial as well as in the related ventricular interval in 84%. NN50 events occurred only in the atrium in 6% and only in the ventricle in 10%. The mean differences between atrial and ventricular SDNN and RMSSD were0.4±2.1ms and ,0.1±3.5 mswith intra-individual differences <1%. The present study described a new method and demonstrated its feasibility to determine atrial as well as ventricular HRV from pacemakermediated intracardiac electrograms. The differences for pNN50 indicate that ventricular HRV did not reflect the changes of sinus node activity in all patients. (PACE 2003; 26:2272,2274) [source]

Atrial Electrogram Amplitude and Efficacy of Cavotricuspid Isthmus Ablation for Atrial Flutter

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2003
MEHMET OZAYDIN
Large atrial electrogram amplitudes recorded in the cavotricuspid isthmus (CTI) may reflect thick atrial musculature. For this reason, in patients with atrial flutter, the efficacy of an application of conventional radiofrequency energy may be related to the amplitude of the local atrial electrogram. In 100 consecutive patients (mean age 59 ± 13 years) with atrial flutter, contiguous applications of radiofrequency energy were delivered in the CTI. The criterion for complete CTI block was the presence of widely split double potentials (>110 ms) along the entire ablation line during pacing from the coronary sinus and posterolateral right atrium. The atrial electrogram amplitude was measured before and after applications of radiofrequency energy at sites of gaps in the ablation line. Complete CTI block was achieved in 90 (90%) of the 100 patients. The mean atrial electrogram amplitudes at gap sites where an application of radiofrequency energy did and did not result in complete block were 0.36 ± 0.42 and 0.67 ± 0.62 mV, respectively (P < 0.01). The positive and negative predictive values (for complete block) of a ,50% decrease in electrogram amplitude after an application of radiofrequency energy were 100% and 35%, respectively. The mean atrial electrogram amplitude is larger at CTI sites where complete isthmus block cannot be achieved with conventional radiofrequency energy. The efficacy of conventional radiofrequency ablation may be improved by identifying areas in the CTI where the voltage is relatively low. (PACE 2003; 26:1859,1863) [source]

Left Atrial Flutter After Segmental Ostial Radiofrequency Catheter Ablation for Pulmonary Vein Isolation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2003
HAKAN ORAL
Segmental ostial ablation to electrically isolate pulmonary veins has been performed for atrial fibrillation. Left atrial flutter that utilized a critical isthmus adjacent to the ostium of the left superior pulmonary vein was diagnosed and successfully ablated in a patient 3 months after a successful pulmonary vein isolation procedure. Documenting the cause of symptoms after pulmonary vein isolation in patients with atrial fibrillation is critical in guiding therapy. (PACE 2003; 26:1417,1419) [source]

P Wave Duration and Morphology Predict Atrial Fibrillation Recurrence in Patients with Sinus Node Dysfunction and Atrial-Based Pacemaker

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 11 2002
ANTONIO DE SISTI
DE SISTI, A., et al.: P Wave Duration and Morphology Predict Atrial Fibrillation Recurrence in Patients with Sinus Node Dysfunction and Atrial-Based Pacemaker. P wave duration and morphology have never been systematically evaluated as markers of AF in patients with a conventional indication to pacing. This study correlated sinus P wave duration and morphology and the incidence of AF in patients with sinus node dysfunction (SND), previous history of AF before implant, and atrial-based pacemaker. Included were 140 patients (86 men, 54 women; mean age 71.8 ± 10.4 years) with recurrent paroxysmal AF and who received a DDD (128 patients) or AAI (12 patients) pacemaker for SND. Forty-nine patients had structural heart disease. Sinus P wave duration and morphology was evaluated in leads II, III. Twenty-two patients had an abnormal P wave morphology, diphasic (+/-) in 5 and notched (+/+) in 17. The basic pacemaker rate was programmed between 60 and 70 beats/min. Rate responsive function was activated in 65 patients. During a follow-up of 27.6 ± 17.8 months, AF was documented in 87 patients. Forty-four patients developed permanent AF, following at least one episode of paroxysmal AF in 26 cases. Statistical analysis used Cox model regression. Univariate predictors of AF (P < 0.10) were drugs (mean: 2 ± 1.4) and DC shock before pacing (16/140 patients), P wave duration (mean 112.5 ± 24.6 ms), basic pacemaker rate (mean 68 ± 5 beats/min), and drugs in the follow-up (mean 1.2 ± 0.94). Multivariate analysis showed that P wave duration (b = 0.013, s.e. = 0.004; P = 0.003), and drugs before pacing (b = 0.2; s.e.= 0.08; P < 0.01) resulted in a significant independent predictor of AF. Actuarial incidence of patients free of AF at 30 months was 35%: 56% in patients with a P wave < 120 ms, and 13% in those with P wave , 120 ms (P < 0.01 by Score test). Univariate predictors of permanent AF were drugs and DC shock before pacing, left atrial size (mean 39 ± 6 mm), P wave duration, abnormal P wave morphology (22/140 patients), and drugs in the follow-up. Multivariate analysis showed that P wave morphology was the most important predictor of permanent AF (b = - 0.56, s.e.= 0.2; P = 0.008). Incidence of patients free of permanent AF at 30 months was 69%: 74% in patients with normal P wave, compared to 28% in the case of abnormal P wave morphology (P < 0.01). P wave duration and morphology are good markers of postpacing AF recurrence in patients with SND and an atrial-based pacemaker. This observation suggests that intra- and interatrial conduction disturbances be extensively evaluated before implantation, and the indication for atrial resynchronization procedures be reevaluated. [source]