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Dhiraj Gupta - One of the best experts on this subject based on the ideXlab platform.
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Reverse electrical and structural remodeling of the left atrium occurs early after pulmonary vein isolation for persistent atrial fibrillation
Journal of Interventional Cardiac Electrophysiology, 2019Co-Authors: Baptiste Maille, Moloy Das, Emmanuel Williams, Christina Ronayne, Richard L. Snowdon, Maureen Morgan, Matthew Shaw, Vivek Chaturvedi, Ahmed El-hussein, Dhiraj GuptaAbstract:PurposeAdverse left atrial (LA) remodeling is known to be associated with persistent atrial fibrillation (PeAF). The time course and pattern of reversal of LA remodeling following catheter ablation is poorly understood. We aimed to evaluate LA chamber volumes and dimensions, LA conduction velocities, and LA bipolar voltages at baseline and at 2 months after catheter ablation for PeAF.MethodsTwenty-three patients with PeAF underwent detailed LA mapping during fixed rate atrial pacing using the CARTO3 navigation system prior to undergoing pulmonary vein isolation. All patients returned for protocol-mandated repeat Electrophysiology Study at 2 months, irrespective of symptoms or arrhythmia recurrence, during which all measurements were repeated using an identical mapping protocol. Patients then underwent daily ECG monitoring for 12 months.ResultsNineteen out of twenty-three (83.6%) patients had durable PVI of all veins at repeat Electrophysiology Study, while 4 (17.4%) patients had late reconnection of a single vein each. In the blinded offline analysis, LA volume at follow-up was significantly lower as compared with baseline (55 ± 14 mL/m^2 vs. 65 ± 15 mL/m^2, P
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Reverse electrical and structural remodeling of the left atrium occurs early after pulmonary vein isolation for persistent atrial fibrillation
Journal of Interventional Cardiac Electrophysiology, 2019Co-Authors: Baptiste Maille, Moloy Das, Emmanuel Williams, Christina Ronayne, Richard L. Snowdon, Maureen Morgan, Matthew Shaw, Vivek Chaturvedi, Ahmed El-hussein, Dhiraj GuptaAbstract:PurposeAdverse left atrial (LA) remodeling is known to be associated with persistent atrial fibrillation (PeAF). The time course and pattern of reversal of LA remodeling following catheter ablation is poorly understood. We aimed to evaluate LA chamber volumes and dimensions, LA conduction velocities, and LA bipolar voltages at baseline and at 2 months after catheter ablation for PeAF.MethodsTwenty-three patients with PeAF underwent detailed LA mapping during fixed rate atrial pacing using the CARTO3 navigation system prior to undergoing pulmonary vein isolation. All patients returned for protocol-mandated repeat Electrophysiology Study at 2 months, irrespective of symptoms or arrhythmia recurrence, during which all measurements were repeated using an identical mapping protocol. Patients then underwent daily ECG monitoring for 12 months.ResultsNineteen out of twenty-three (83.6%) patients had durable PVI of all veins at repeat Electrophysiology Study, while 4 (17.4%) patients had late reconnection of a single vein each. In the blinded offline analysis, LA volume at follow-up was significantly lower as compared with baseline (55 ± 14 mL/m^2 vs. 65 ± 15 mL/m^2, P
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Reablated Sites of Acute Reconnection After Pulmonary Vein Isolation Do Not Predict Sites of Late Reconnection at Repeat Electrophysiology Study.
Journal of cardiovascular electrophysiology, 2016Co-Authors: Moloy Das, Christina Ronayne, Maureen Morgan, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Richard Snowdon, Simon Modi, Dhiraj GuptaAbstract:Introduction Acute reconnection of pulmonary veins (PVs) is frequently seen in the waiting period following pulmonary vein isolation (PVI). There are concerns that reablation at these sites may not be durably effective due to tissue edema caused by the initial ablation. We aimed to prospectively Study the relationship between acute and late reconnection. Methods and results Wide-area circumferential PVI was performed in 40 paroxysmal AF patients. Spontaneous reconnection was assessed after a minimum 20-minute waiting period, with adenosine administered to unmask dormant reconnection. All sites of acute reconnection were ablated to reisolate the PV. All 40 patients then underwent repeat Electrophysiology Study after 2 months, regardless of symptoms, to identify late reconnection. Sites of acute and late reconnection were compared according to a 12-segment PVI model. Acute reconnection was seen in 28 (6%) PVI segments in 20 (50%) patients, affecting 24/160 (15%) PVs. All were successfully reisolated. At repeat Electrophysiology Study, 51 (11%) PVI segments were reconnected in 25 (62%) patients, affecting 41 (25%) PVs. The proportion of PVI segments with and without acute reconnection exhibiting late reconnection at repeat Study was no different (14% vs. 10%, P = 0.524). There was also no difference in late reconnection between PVI circles or patients with and without acute reconnection. Conclusion Most PVI segments that undergo further ablation for acute reconnection show persistent isolation at repeat Electrophysiology Study, and the rate of late reconnection for these segments is no different to that for segments that did not acutely reconnect. This implies that effective reablation is delivered at these sites.
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recurrence of atrial tachyarrhythmia during the second month of the blanking period is associated with more extensive pulmonary vein reconnection at repeat Electrophysiology Study
Circulation-arrhythmia and Electrophysiology, 2015Co-Authors: Moloy Das, Maureen Morgan, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Richard Snowdon, Simon Modi, Ben Lodge, Dhiraj GuptaAbstract:Background— Current guidelines recommend a 3-month blanking period after pulmonary vein isolation (PVI) as early recurrence of atrial tachyarrhythmia (ERAT) may be due to transient proarrhythmic factors. However, studies have suggested that these factors resolve by 1 month. PV reconnection (PVrc) is strongly associated with postblanking AT recurrence in paroxysmal atrial fibrillation. We hypothesized that ERAT occurring beyond 4 weeks after PVI is associated with PVrc at repeat Electrophysiology Study. Methods and Results— Forty patients with paroxysmal atrial fibrillation underwent mandatory repeat Electrophysiology Study 2 months after PVI, regardless of symptoms, to document the number of reconnected PVs. Antiarrhythmic drugs, including β-blockers, were discontinued 4 weeks after PVI. Patients were instructed to record a 30-second ECG everyday between the 2 procedures using a portable monitor, with additional recordings for symptoms. ERAT was defined as ≥30 seconds of AT. Patients recorded a total of 3293 ECGs. Four (10%) patients had ERAT in the first 4 weeks (M1) only, 2 (5%) in month 2 (M2) only, and 11 (28%) in both. PVrc of 1 PV was identified in 12 (30%) patients and of >1 PV in 13 (32%) patients. ERAT in M2 was associated with PVrc, whereas M1 was not (11/13 [85%] versus 0/4 [0%]; P =0.006). M2 ERAT was strongly associated with PVrc of >1 PV (10/13 [77%] versus 3/27 [11%] without M2 ERAT; P <0.0001). Conclusions— ERAT occurring beyond 4 weeks after PVI is associated with PVrc and particularly of PVrc of >1 PV. ERAT confined to M1 is unrelated to underlying PVrc. The relationship between ERAT beyond 4 weeks after PVI and postblanking AT recurrence merits further investigation.
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Recurrence of Atrial Tachyarrhythmia During the Second Month of the Blanking Period Is Associated With More Extensive Pulmonary Vein Reconnection at Repeat Electrophysiology Study
Circulation. Arrhythmia and electrophysiology, 2015Co-Authors: Moloy Das, Maureen Morgan, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Richard Snowdon, Simon Modi, Ben Lodge, Dhiraj GuptaAbstract:Background— Current guidelines recommend a 3-month blanking period after pulmonary vein isolation (PVI) as early recurrence of atrial tachyarrhythmia (ERAT) may be due to transient proarrhythmic factors. However, studies have suggested that these factors resolve by 1 month. PV reconnection (PVrc) is strongly associated with postblanking AT recurrence in paroxysmal atrial fibrillation. We hypothesized that ERAT occurring beyond 4 weeks after PVI is associated with PVrc at repeat Electrophysiology Study. Methods and Results— Forty patients with paroxysmal atrial fibrillation underwent mandatory repeat Electrophysiology Study 2 months after PVI, regardless of symptoms, to document the number of reconnected PVs. Antiarrhythmic drugs, including β-blockers, were discontinued 4 weeks after PVI. Patients were instructed to record a 30-second ECG everyday between the 2 procedures using a portable monitor, with additional recordings for symptoms. ERAT was defined as ≥30 seconds of AT. Patients recorded a total of 3293 ECGs. Four (10%) patients had ERAT in the first 4 weeks (M1) only, 2 (5%) in month 2 (M2) only, and 11 (28%) in both. PVrc of 1 PV was identified in 12 (30%) patients and of >1 PV in 13 (32%) patients. ERAT in M2 was associated with PVrc, whereas M1 was not (11/13 [85%] versus 0/4 [0%]; P =0.006). M2 ERAT was strongly associated with PVrc of >1 PV (10/13 [77%] versus 3/27 [11%] without M2 ERAT; P 1 PV. ERAT confined to M1 is unrelated to underlying PVrc. The relationship between ERAT beyond 4 weeks after PVI and postblanking AT recurrence merits further investigation.
Albert L Waldo - One of the best experts on this subject based on the ideXlab platform.
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Insights into the Electrophysiology Study versus electrocardiographic monitoring trial: Its programmed stimulation protocol may introduce bias when assessing long-term antiarrhythmic drug therapy
Journal of the American College of Cardiology, 1995Co-Authors: Lee A Biblo, Mark D. Carlson, Albert L WaldoAbstract:Abstract Objectives . We hypothesized that if the Electrophysiology Study Versus Electrocardiographic Monitoring (ESVEM) trial programmed stimulation protocol misclassified some drug trials as effective, then the misclassification rate would be proportionally greater for drugs other than sotalol. Background . In the ESVEM trial, patients treated with sotalol had fewer arrhythmic recurrences than those treated with other antiarrhythmic drugs despite similar efficacy predictions during electrophysiologic testing. Methods . We retrospectively compared the standard programmed stimulation protocol used at Case Western Reserve University, which used three extrastimuli during all follow-up studies, with the ESVEM protocol in 176 antiarrhythmic drug trials: sotalol (n = 54), procainamide (n = 73) and quinidine/mexiletine (n = 49). Results . Predictions of efficacy were higher in the sotalol trials (14 of 54 standard, 20 of 54 ESVEM) than in procainamide trials (7 of 73 standard, 14 of 73 ESVEM) or quinidine/mexiletine trials (1 of 49 standard, 7 of 49 ESVEM). Thus, the two protocols classified 19 of 176 trials differently: not effective by the standard protocol but effective by the ESVEM trial. Discordant predictions of drug efficacy constituted a smaller proportion of ESVEM protocol efficacy predictions for sotalol (6 [30%] of 20) than for the other drugs (13 [62%] of 21, p ⩽ 0.05). Conclusions . In the present Study, the ESVEM programmed stimulation protocol predicted efficacy more often than the standard protocol. Discordant predictions represented a smaller portion of efficacy predictions for sotalol than for the other drugs. Thus, in the ESVEM trial, the superior long-term follow-up observed in patients assigned to sotalol may have been an artifact of the stimulation protocol utilized by the ESVEM investigators.
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Insights into the Electrophysiology Study versus electrocardiographic monitoring trial: Its programmed stimulation protocol may introduce bias when assessing long-term antiarrhythmic drug therapy
Journal of the American College of Cardiology, 1995Co-Authors: Lee A Biblo, Mark D. Carlson, Albert L WaldoAbstract:Abstract Objectives . We hypothesized that if the Electrophysiology Study Versus Electrocardiographic Monitoring (ESVEM) trial programmed stimulation protocol misclassified some drug trials as effective, then the misclassification rate would be proportionally greater for drugs other than sotalol. Background . In the ESVEM trial, patients treated with sotalol had fewer arrhythmic recurrences than those treated with other antiarrhythmic drugs despite similar efficacy predictions during electrophysiologic testing. Methods . We retrospectively compared the standard programmed stimulation protocol used at Case Western Reserve University, which used three extrastimuli during all follow-up studies, with the ESVEM protocol in 176 antiarrhythmic drug trials: sotalol (n = 54), procainamide (n = 73) and quinidine/mexiletine (n = 49). Results . Predictions of efficacy were higher in the sotalol trials (14 of 54 standard, 20 of 54 ESVEM) than in procainamide trials (7 of 73 standard, 14 of 73 ESVEM) or quinidine/mexiletine trials (1 of 49 standard, 7 of 49 ESVEM). Thus, the two protocols classified 19 of 176 trials differently: not effective by the standard protocol but effective by the ESVEM trial. Discordant predictions of drug efficacy constituted a smaller proportion of ESVEM protocol efficacy predictions for sotalol (6 [30%] of 20) than for the other drugs (13 [62%] of 21, p ⩽ 0.05). Conclusions . In the present Study, the ESVEM programmed stimulation protocol predicted efficacy more often than the standard protocol. Discordant predictions represented a smaller portion of efficacy predictions for sotalol than for the other drugs. Thus, in the ESVEM trial, the superior long-term follow-up observed in patients assigned to sotalol may have been an artifact of the stimulation protocol utilized by the ESVEM investigators.
Moloy Das - One of the best experts on this subject based on the ideXlab platform.
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Reverse electrical and structural remodeling of the left atrium occurs early after pulmonary vein isolation for persistent atrial fibrillation
Journal of Interventional Cardiac Electrophysiology, 2019Co-Authors: Baptiste Maille, Moloy Das, Emmanuel Williams, Christina Ronayne, Richard L. Snowdon, Maureen Morgan, Matthew Shaw, Vivek Chaturvedi, Ahmed El-hussein, Dhiraj GuptaAbstract:PurposeAdverse left atrial (LA) remodeling is known to be associated with persistent atrial fibrillation (PeAF). The time course and pattern of reversal of LA remodeling following catheter ablation is poorly understood. We aimed to evaluate LA chamber volumes and dimensions, LA conduction velocities, and LA bipolar voltages at baseline and at 2 months after catheter ablation for PeAF.MethodsTwenty-three patients with PeAF underwent detailed LA mapping during fixed rate atrial pacing using the CARTO3 navigation system prior to undergoing pulmonary vein isolation. All patients returned for protocol-mandated repeat Electrophysiology Study at 2 months, irrespective of symptoms or arrhythmia recurrence, during which all measurements were repeated using an identical mapping protocol. Patients then underwent daily ECG monitoring for 12 months.ResultsNineteen out of twenty-three (83.6%) patients had durable PVI of all veins at repeat Electrophysiology Study, while 4 (17.4%) patients had late reconnection of a single vein each. In the blinded offline analysis, LA volume at follow-up was significantly lower as compared with baseline (55 ± 14 mL/m^2 vs. 65 ± 15 mL/m^2, P
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Reverse electrical and structural remodeling of the left atrium occurs early after pulmonary vein isolation for persistent atrial fibrillation
Journal of Interventional Cardiac Electrophysiology, 2019Co-Authors: Baptiste Maille, Moloy Das, Emmanuel Williams, Christina Ronayne, Richard L. Snowdon, Maureen Morgan, Matthew Shaw, Vivek Chaturvedi, Ahmed El-hussein, Dhiraj GuptaAbstract:PurposeAdverse left atrial (LA) remodeling is known to be associated with persistent atrial fibrillation (PeAF). The time course and pattern of reversal of LA remodeling following catheter ablation is poorly understood. We aimed to evaluate LA chamber volumes and dimensions, LA conduction velocities, and LA bipolar voltages at baseline and at 2 months after catheter ablation for PeAF.MethodsTwenty-three patients with PeAF underwent detailed LA mapping during fixed rate atrial pacing using the CARTO3 navigation system prior to undergoing pulmonary vein isolation. All patients returned for protocol-mandated repeat Electrophysiology Study at 2 months, irrespective of symptoms or arrhythmia recurrence, during which all measurements were repeated using an identical mapping protocol. Patients then underwent daily ECG monitoring for 12 months.ResultsNineteen out of twenty-three (83.6%) patients had durable PVI of all veins at repeat Electrophysiology Study, while 4 (17.4%) patients had late reconnection of a single vein each. In the blinded offline analysis, LA volume at follow-up was significantly lower as compared with baseline (55 ± 14 mL/m^2 vs. 65 ± 15 mL/m^2, P
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ablation index a novel marker of ablation lesion quality prediction of pulmonary vein reconnection at repeat Electrophysiology Study and regional differences in target values
Europace, 2016Co-Authors: Moloy Das, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Jonathan J Loveday, Sean Gomes, Yawer Saeed, Laura J Bonnett, Richard SnowdonAbstract:Aims Force–Time Integral (FTI) is commonly used as a marker of ablation lesion quality during pulmonary vein isolation (PVI), but does not incorporate power. Ablation Index (AI) is a novel lesion quality marker that utilizes contact force, time, and power in a weighted formula. Furthermore, only a single FTI target value has been suggested despite regional variation in left atrial wall thickness. We aimed to Study AI's and FTI's relationships with PV reconnection at repeat Electrophysiology Study, and regional threshold values that predicted no reconnection. Methods and results Forty paroxysmal atrial fibrillation patients underwent contact force-guided PVI, and the minimum and mean AI and FTI values for each segment were identified according to a 12-segment model. All patients underwent repeat Electrophysiology Study at 2 months, regardless of symptoms, to identify sites of PV reconnection. Late PV reconnection was seen in 53 (11%) segments in 25 (62%) patients. Reconnected segments had significantly lower minimum AI [308 (252–336) vs. 373 (323–423), P < 0.0001] and FTI [137 (92–182) vs. 228 (157–334), P < 0.0001] compared with non-reconnected segments. Minimum AI and FTI were both independently predictive, but AI had a smaller P value. Higher minimum AI and FTI values were required to avoid reconnection in anterior/roof segments than for posterior/inferior segments ( P < 0.0001). No reconnection was seen where the minimum AI value was ≥370 for posterior/inferior segments and ≥480 for anterior/roof segments. Conclusion The minimum AI value in a PVI segment is independently predictive of reconnection of that segment at repeat Electrophysiology Study. Higher AI and FTI values are required for anterior/roof segments than for posterior/inferior segments to prevent reconnection.
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Reablated Sites of Acute Reconnection After Pulmonary Vein Isolation Do Not Predict Sites of Late Reconnection at Repeat Electrophysiology Study.
Journal of cardiovascular electrophysiology, 2016Co-Authors: Moloy Das, Christina Ronayne, Maureen Morgan, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Richard Snowdon, Simon Modi, Dhiraj GuptaAbstract:Introduction Acute reconnection of pulmonary veins (PVs) is frequently seen in the waiting period following pulmonary vein isolation (PVI). There are concerns that reablation at these sites may not be durably effective due to tissue edema caused by the initial ablation. We aimed to prospectively Study the relationship between acute and late reconnection. Methods and results Wide-area circumferential PVI was performed in 40 paroxysmal AF patients. Spontaneous reconnection was assessed after a minimum 20-minute waiting period, with adenosine administered to unmask dormant reconnection. All sites of acute reconnection were ablated to reisolate the PV. All 40 patients then underwent repeat Electrophysiology Study after 2 months, regardless of symptoms, to identify late reconnection. Sites of acute and late reconnection were compared according to a 12-segment PVI model. Acute reconnection was seen in 28 (6%) PVI segments in 20 (50%) patients, affecting 24/160 (15%) PVs. All were successfully reisolated. At repeat Electrophysiology Study, 51 (11%) PVI segments were reconnected in 25 (62%) patients, affecting 41 (25%) PVs. The proportion of PVI segments with and without acute reconnection exhibiting late reconnection at repeat Study was no different (14% vs. 10%, P = 0.524). There was also no difference in late reconnection between PVI circles or patients with and without acute reconnection. Conclusion Most PVI segments that undergo further ablation for acute reconnection show persistent isolation at repeat Electrophysiology Study, and the rate of late reconnection for these segments is no different to that for segments that did not acutely reconnect. This implies that effective reablation is delivered at these sites.
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recurrence of atrial tachyarrhythmia during the second month of the blanking period is associated with more extensive pulmonary vein reconnection at repeat Electrophysiology Study
Circulation-arrhythmia and Electrophysiology, 2015Co-Authors: Moloy Das, Maureen Morgan, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Richard Snowdon, Simon Modi, Ben Lodge, Dhiraj GuptaAbstract:Background— Current guidelines recommend a 3-month blanking period after pulmonary vein isolation (PVI) as early recurrence of atrial tachyarrhythmia (ERAT) may be due to transient proarrhythmic factors. However, studies have suggested that these factors resolve by 1 month. PV reconnection (PVrc) is strongly associated with postblanking AT recurrence in paroxysmal atrial fibrillation. We hypothesized that ERAT occurring beyond 4 weeks after PVI is associated with PVrc at repeat Electrophysiology Study. Methods and Results— Forty patients with paroxysmal atrial fibrillation underwent mandatory repeat Electrophysiology Study 2 months after PVI, regardless of symptoms, to document the number of reconnected PVs. Antiarrhythmic drugs, including β-blockers, were discontinued 4 weeks after PVI. Patients were instructed to record a 30-second ECG everyday between the 2 procedures using a portable monitor, with additional recordings for symptoms. ERAT was defined as ≥30 seconds of AT. Patients recorded a total of 3293 ECGs. Four (10%) patients had ERAT in the first 4 weeks (M1) only, 2 (5%) in month 2 (M2) only, and 11 (28%) in both. PVrc of 1 PV was identified in 12 (30%) patients and of >1 PV in 13 (32%) patients. ERAT in M2 was associated with PVrc, whereas M1 was not (11/13 [85%] versus 0/4 [0%]; P =0.006). M2 ERAT was strongly associated with PVrc of >1 PV (10/13 [77%] versus 3/27 [11%] without M2 ERAT; P <0.0001). Conclusions— ERAT occurring beyond 4 weeks after PVI is associated with PVrc and particularly of PVrc of >1 PV. ERAT confined to M1 is unrelated to underlying PVrc. The relationship between ERAT beyond 4 weeks after PVI and postblanking AT recurrence merits further investigation.
Richard Snowdon - One of the best experts on this subject based on the ideXlab platform.
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ablation index a novel marker of ablation lesion quality prediction of pulmonary vein reconnection at repeat Electrophysiology Study and regional differences in target values
Europace, 2016Co-Authors: Moloy Das, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Jonathan J Loveday, Sean Gomes, Yawer Saeed, Laura J Bonnett, Richard SnowdonAbstract:Aims Force–Time Integral (FTI) is commonly used as a marker of ablation lesion quality during pulmonary vein isolation (PVI), but does not incorporate power. Ablation Index (AI) is a novel lesion quality marker that utilizes contact force, time, and power in a weighted formula. Furthermore, only a single FTI target value has been suggested despite regional variation in left atrial wall thickness. We aimed to Study AI's and FTI's relationships with PV reconnection at repeat Electrophysiology Study, and regional threshold values that predicted no reconnection. Methods and results Forty paroxysmal atrial fibrillation patients underwent contact force-guided PVI, and the minimum and mean AI and FTI values for each segment were identified according to a 12-segment model. All patients underwent repeat Electrophysiology Study at 2 months, regardless of symptoms, to identify sites of PV reconnection. Late PV reconnection was seen in 53 (11%) segments in 25 (62%) patients. Reconnected segments had significantly lower minimum AI [308 (252–336) vs. 373 (323–423), P < 0.0001] and FTI [137 (92–182) vs. 228 (157–334), P < 0.0001] compared with non-reconnected segments. Minimum AI and FTI were both independently predictive, but AI had a smaller P value. Higher minimum AI and FTI values were required to avoid reconnection in anterior/roof segments than for posterior/inferior segments ( P < 0.0001). No reconnection was seen where the minimum AI value was ≥370 for posterior/inferior segments and ≥480 for anterior/roof segments. Conclusion The minimum AI value in a PVI segment is independently predictive of reconnection of that segment at repeat Electrophysiology Study. Higher AI and FTI values are required for anterior/roof segments than for posterior/inferior segments to prevent reconnection.
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Reablated Sites of Acute Reconnection After Pulmonary Vein Isolation Do Not Predict Sites of Late Reconnection at Repeat Electrophysiology Study.
Journal of cardiovascular electrophysiology, 2016Co-Authors: Moloy Das, Christina Ronayne, Maureen Morgan, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Richard Snowdon, Simon Modi, Dhiraj GuptaAbstract:Introduction Acute reconnection of pulmonary veins (PVs) is frequently seen in the waiting period following pulmonary vein isolation (PVI). There are concerns that reablation at these sites may not be durably effective due to tissue edema caused by the initial ablation. We aimed to prospectively Study the relationship between acute and late reconnection. Methods and results Wide-area circumferential PVI was performed in 40 paroxysmal AF patients. Spontaneous reconnection was assessed after a minimum 20-minute waiting period, with adenosine administered to unmask dormant reconnection. All sites of acute reconnection were ablated to reisolate the PV. All 40 patients then underwent repeat Electrophysiology Study after 2 months, regardless of symptoms, to identify late reconnection. Sites of acute and late reconnection were compared according to a 12-segment PVI model. Acute reconnection was seen in 28 (6%) PVI segments in 20 (50%) patients, affecting 24/160 (15%) PVs. All were successfully reisolated. At repeat Electrophysiology Study, 51 (11%) PVI segments were reconnected in 25 (62%) patients, affecting 41 (25%) PVs. The proportion of PVI segments with and without acute reconnection exhibiting late reconnection at repeat Study was no different (14% vs. 10%, P = 0.524). There was also no difference in late reconnection between PVI circles or patients with and without acute reconnection. Conclusion Most PVI segments that undergo further ablation for acute reconnection show persistent isolation at repeat Electrophysiology Study, and the rate of late reconnection for these segments is no different to that for segments that did not acutely reconnect. This implies that effective reablation is delivered at these sites.
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recurrence of atrial tachyarrhythmia during the second month of the blanking period is associated with more extensive pulmonary vein reconnection at repeat Electrophysiology Study
Circulation-arrhythmia and Electrophysiology, 2015Co-Authors: Moloy Das, Maureen Morgan, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Richard Snowdon, Simon Modi, Ben Lodge, Dhiraj GuptaAbstract:Background— Current guidelines recommend a 3-month blanking period after pulmonary vein isolation (PVI) as early recurrence of atrial tachyarrhythmia (ERAT) may be due to transient proarrhythmic factors. However, studies have suggested that these factors resolve by 1 month. PV reconnection (PVrc) is strongly associated with postblanking AT recurrence in paroxysmal atrial fibrillation. We hypothesized that ERAT occurring beyond 4 weeks after PVI is associated with PVrc at repeat Electrophysiology Study. Methods and Results— Forty patients with paroxysmal atrial fibrillation underwent mandatory repeat Electrophysiology Study 2 months after PVI, regardless of symptoms, to document the number of reconnected PVs. Antiarrhythmic drugs, including β-blockers, were discontinued 4 weeks after PVI. Patients were instructed to record a 30-second ECG everyday between the 2 procedures using a portable monitor, with additional recordings for symptoms. ERAT was defined as ≥30 seconds of AT. Patients recorded a total of 3293 ECGs. Four (10%) patients had ERAT in the first 4 weeks (M1) only, 2 (5%) in month 2 (M2) only, and 11 (28%) in both. PVrc of 1 PV was identified in 12 (30%) patients and of >1 PV in 13 (32%) patients. ERAT in M2 was associated with PVrc, whereas M1 was not (11/13 [85%] versus 0/4 [0%]; P =0.006). M2 ERAT was strongly associated with PVrc of >1 PV (10/13 [77%] versus 3/27 [11%] without M2 ERAT; P <0.0001). Conclusions— ERAT occurring beyond 4 weeks after PVI is associated with PVrc and particularly of PVrc of >1 PV. ERAT confined to M1 is unrelated to underlying PVrc. The relationship between ERAT beyond 4 weeks after PVI and postblanking AT recurrence merits further investigation.
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Recurrence of Atrial Tachyarrhythmia During the Second Month of the Blanking Period Is Associated With More Extensive Pulmonary Vein Reconnection at Repeat Electrophysiology Study
Circulation. Arrhythmia and electrophysiology, 2015Co-Authors: Moloy Das, Maureen Morgan, Gareth J. Wynn, Johan E.p. Waktare, Derick Todd, Mark Hall, Richard Snowdon, Simon Modi, Ben Lodge, Dhiraj GuptaAbstract:Background— Current guidelines recommend a 3-month blanking period after pulmonary vein isolation (PVI) as early recurrence of atrial tachyarrhythmia (ERAT) may be due to transient proarrhythmic factors. However, studies have suggested that these factors resolve by 1 month. PV reconnection (PVrc) is strongly associated with postblanking AT recurrence in paroxysmal atrial fibrillation. We hypothesized that ERAT occurring beyond 4 weeks after PVI is associated with PVrc at repeat Electrophysiology Study. Methods and Results— Forty patients with paroxysmal atrial fibrillation underwent mandatory repeat Electrophysiology Study 2 months after PVI, regardless of symptoms, to document the number of reconnected PVs. Antiarrhythmic drugs, including β-blockers, were discontinued 4 weeks after PVI. Patients were instructed to record a 30-second ECG everyday between the 2 procedures using a portable monitor, with additional recordings for symptoms. ERAT was defined as ≥30 seconds of AT. Patients recorded a total of 3293 ECGs. Four (10%) patients had ERAT in the first 4 weeks (M1) only, 2 (5%) in month 2 (M2) only, and 11 (28%) in both. PVrc of 1 PV was identified in 12 (30%) patients and of >1 PV in 13 (32%) patients. ERAT in M2 was associated with PVrc, whereas M1 was not (11/13 [85%] versus 0/4 [0%]; P =0.006). M2 ERAT was strongly associated with PVrc of >1 PV (10/13 [77%] versus 3/27 [11%] without M2 ERAT; P 1 PV. ERAT confined to M1 is unrelated to underlying PVrc. The relationship between ERAT beyond 4 weeks after PVI and postblanking AT recurrence merits further investigation.
Lee A Biblo - One of the best experts on this subject based on the ideXlab platform.
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Insights into the Electrophysiology Study versus electrocardiographic monitoring trial: Its programmed stimulation protocol may introduce bias when assessing long-term antiarrhythmic drug therapy
Journal of the American College of Cardiology, 1995Co-Authors: Lee A Biblo, Mark D. Carlson, Albert L WaldoAbstract:Abstract Objectives . We hypothesized that if the Electrophysiology Study Versus Electrocardiographic Monitoring (ESVEM) trial programmed stimulation protocol misclassified some drug trials as effective, then the misclassification rate would be proportionally greater for drugs other than sotalol. Background . In the ESVEM trial, patients treated with sotalol had fewer arrhythmic recurrences than those treated with other antiarrhythmic drugs despite similar efficacy predictions during electrophysiologic testing. Methods . We retrospectively compared the standard programmed stimulation protocol used at Case Western Reserve University, which used three extrastimuli during all follow-up studies, with the ESVEM protocol in 176 antiarrhythmic drug trials: sotalol (n = 54), procainamide (n = 73) and quinidine/mexiletine (n = 49). Results . Predictions of efficacy were higher in the sotalol trials (14 of 54 standard, 20 of 54 ESVEM) than in procainamide trials (7 of 73 standard, 14 of 73 ESVEM) or quinidine/mexiletine trials (1 of 49 standard, 7 of 49 ESVEM). Thus, the two protocols classified 19 of 176 trials differently: not effective by the standard protocol but effective by the ESVEM trial. Discordant predictions of drug efficacy constituted a smaller proportion of ESVEM protocol efficacy predictions for sotalol (6 [30%] of 20) than for the other drugs (13 [62%] of 21, p ⩽ 0.05). Conclusions . In the present Study, the ESVEM programmed stimulation protocol predicted efficacy more often than the standard protocol. Discordant predictions represented a smaller portion of efficacy predictions for sotalol than for the other drugs. Thus, in the ESVEM trial, the superior long-term follow-up observed in patients assigned to sotalol may have been an artifact of the stimulation protocol utilized by the ESVEM investigators.
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Insights into the Electrophysiology Study versus electrocardiographic monitoring trial: Its programmed stimulation protocol may introduce bias when assessing long-term antiarrhythmic drug therapy
Journal of the American College of Cardiology, 1995Co-Authors: Lee A Biblo, Mark D. Carlson, Albert L WaldoAbstract:Abstract Objectives . We hypothesized that if the Electrophysiology Study Versus Electrocardiographic Monitoring (ESVEM) trial programmed stimulation protocol misclassified some drug trials as effective, then the misclassification rate would be proportionally greater for drugs other than sotalol. Background . In the ESVEM trial, patients treated with sotalol had fewer arrhythmic recurrences than those treated with other antiarrhythmic drugs despite similar efficacy predictions during electrophysiologic testing. Methods . We retrospectively compared the standard programmed stimulation protocol used at Case Western Reserve University, which used three extrastimuli during all follow-up studies, with the ESVEM protocol in 176 antiarrhythmic drug trials: sotalol (n = 54), procainamide (n = 73) and quinidine/mexiletine (n = 49). Results . Predictions of efficacy were higher in the sotalol trials (14 of 54 standard, 20 of 54 ESVEM) than in procainamide trials (7 of 73 standard, 14 of 73 ESVEM) or quinidine/mexiletine trials (1 of 49 standard, 7 of 49 ESVEM). Thus, the two protocols classified 19 of 176 trials differently: not effective by the standard protocol but effective by the ESVEM trial. Discordant predictions of drug efficacy constituted a smaller proportion of ESVEM protocol efficacy predictions for sotalol (6 [30%] of 20) than for the other drugs (13 [62%] of 21, p ⩽ 0.05). Conclusions . In the present Study, the ESVEM programmed stimulation protocol predicted efficacy more often than the standard protocol. Discordant predictions represented a smaller portion of efficacy predictions for sotalol than for the other drugs. Thus, in the ESVEM trial, the superior long-term follow-up observed in patients assigned to sotalol may have been an artifact of the stimulation protocol utilized by the ESVEM investigators.