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Atul Verma - One of the best experts on this subject based on the ideXlab platform.
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Ablation of Persistent Atrial Fibrillation: Challenges and Solutions
Journal of cardiovascular electrophysiology, 2019Co-Authors: Maria Terricabras, Jonathan P. Piccini, Atul VermaAbstract:Catheter ablation is commonly used for treatment of Persistent Atrial Fibrillation (AF). Pulmonary vein isolation (PVI) is still the cornerstone for the procedure, however, outcomes are consistently lower compared to paroxysmal AF. It is hypothesized that it could be due to lack of durable lesions or the presence of non-PV targets that remain after PVI. Numerous advances in ablation catheter technologies and mapping systems may potentially achieve lower recurrence rates in the future. Ongoing research is required to discover the best technique for Persistent AF ablation. The purpose of this review is to describe the new, developing technologies that may improve the outcome of this procedure in the Persistent AF population.
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Approaches to Catheter Ablation for Persistent Atrial Fibrillation
The New England journal of medicine, 2015Co-Authors: Atul Verma, Chen-yang Jiang, Timothy R. Betts, Jian Chen, I. Deisenhofer, Roberto Mantovan, Laurent Macle, Carlos A. Morillo, Wilhelm Haverkamp, Rukshen WeerasooriyaAbstract:BackgroundCatheter ablation is less successful for Persistent Atrial Fibrillation than for paroxysmal Atrial Fibrillation. Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in Persistent Atrial Fibrillation. MethodsWe randomly assigned 589 patients with Persistent Atrial Fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone (67 patients), pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity (263 patients), or pulmonary-vein isolation plus additional linear ablation across the left Atrial roof and mitral valve isthmus (259 patients). The duration of follow-up was 18 months. The primary end point was freedom from any documented recurrence of Atrial Fibrillation lasting longer than 30 seconds after a single ablation procedure. ResultsProcedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures (P
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approaches to catheter ablation for Persistent Atrial Fibrillation
The New England Journal of Medicine, 2015Co-Authors: Atul Verma, Chen-yang Jiang, Timothy R. Betts, Jian Chen, I. Deisenhofer, Roberto Mantovan, Laurent Macle, Carlos A. Morillo, Wilhelm Haverkamp, Rukshen WeerasooriyaAbstract:BackgroundCatheter ablation is less successful for Persistent Atrial Fibrillation than for paroxysmal Atrial Fibrillation. Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in Persistent Atrial Fibrillation. MethodsWe randomly assigned 589 patients with Persistent Atrial Fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone (67 patients), pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity (263 patients), or pulmonary-vein isolation plus additional linear ablation across the left Atrial roof and mitral valve isthmus (259 patients). The duration of follow-up was 18 months. The primary end point was freedom from any documented recurrence of Atrial Fibrillation lasting longer than 30 seconds after a single ablation procedure. ResultsProcedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures (P<0.001). After 18 months, 59% of patients ass...
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The techniques for catheter ablation of paroxysmal and Persistent Atrial Fibrillation: a systematic review.
Current opinion in cardiology, 2011Co-Authors: Atul VermaAbstract:PURPOSE OF REVIEW Ablation for Atrial Fibrillation has become a widely accepted and practiced treatment for this arrhythmia. However, the technique for ablation has evolved over time, particularly for the two distinct groups of paroxysmal and Persistent Atrial Fibrillation. This review outlines the optimal techniques for ablation of these different subgroups of Atrial Fibrillation. RECENT FINDINGS The most commonly applied techniques for Atrial Fibrillation ablation include isolation of the pulmonary venous antra, left-Atrial linear ablation, and ablation of complex fractionated electrograms (CFEs) during Atrial Fibrillation. For patients with paroxysmal Atrial Fibrillation, isolation of the pulmonary venous antra appears to be sufficient, with effective and reproducible outcomes being reported across many centers. For Persistent Atrial Fibrillation, the outcome of catheter ablation is less efficacious. It is widely believed that additional ablation targeting the substrate of Atrial Fibrillation maintenance is required beyond pulmonary venous isolation. Linear and CFE ablation have been the most commonly employed adjuvant strategies employed, but neither has been adequately compared with the other to make definitive recommendations. SUMMARY Pulmonary venous antral isolation is the cornerstone of ablation of both paroxysmal and Persistent Atrial Fibrillation. However, to obtain better outcomes in Persistent Atrial Fibrillation, further adjuvant ablation, in the form of either linear or CFE ablation, will likely have to be performed to achieve comparable success rates.
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Persistent Atrial Fibrillation: current approach and controversies.
Current opinion in cardiology, 2010Co-Authors: Ratika Parkash, Atul Verma, Antony S L TangAbstract:PURPOSE OF REVIEW To address the changing definition of Atrial Fibrillation as it reflects the major paradigm shift in the comprehension of mechanisms underlying Atrial Fibrillation and the possible treatment options targeting Persistent Atrial Fibrillation. RECENT FINDINGS Persistent Atrial Fibrillation exists in a spectrum that is linked to paroxysmal Atrial Fibrillation. The mechanism underlying Persistent Atrial Fibrillation has evolved significantly but requires further understanding in order to improve its management. The role of external factors, such as blood pressure, on the development of Persistent Atrial Fibrillation and its underlying substrate require further exploration. Catheter ablation has evolved significantly but controversy remains regarding the optimal approach for Persistent Atrial Fibrillation. SUMMARY The definition of Atrial Fibrillation has evolved significantly as a result of knowledge gathered from therapy with catheter ablation for Atrial Fibrillation. Further trials are required to investigate the causes, mechanisms and optimal therapies for Persistent Atrial Fibrillation.
Alan Bulava - One of the best experts on this subject based on the ideXlab platform.
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Delayed Electroanatomic Mapping After Surgical Ablation for Persistent Atrial Fibrillation.
The Annals of thoracic surgery, 2017Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech KurfirstAbstract:Background Long-term efficacy of catheter-based treatment of Persistent Atrial Fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently but their true efficacy has never been systematically tested. Methods Seventy patients (median age 63.5 years) with Persistent Atrial Fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein (PV) isolation, linear ablation, Marshal ligament disruption, and exclusion of the left Atrial appendage. The procedure was followed by electroanatomic mapping 2 to 3 months later. Results Only 76% of patients were in sinus rhythm at the beginning of electroanatomic mapping. Right PVs were found isolated in a higher proportion of patients compared with left PVs (75.7% versus 91.4%, p Conclusions Epicardial PV isolation was successful in the majority of patients, but was underwhelming with regard to isolation of the left PVs. Effective epicardially placed linear lines were rare. Our results highlight the significant limitations associated with a single-stage surgical approach and underline the necessity for a two-staged hybrid approach in the treatment of Persistent Atrial Fibrillation.
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Correlates of Arrhythmia Recurrence After Hybrid Epi- and Endocardial Radiofrequency Ablation for Persistent Atrial Fibrillation
Circulation. Arrhythmia and electrophysiology, 2017Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech Kurfirst, Jiri Hanis, Martin Eisenberger, Ladislav DušekAbstract:Background—Long-term efficacy of catheter-based treatment of Persistent Atrial Fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently, but thei...
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Sequential Hybrid Procedure for Persistent Atrial Fibrillation
Journal of the American Heart Association, 2015Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech Kurfirst, Jiri Hanis, Martin Eisenberger, Ladislav PešlAbstract:Background Catheter ablation of Persistent Atrial Fibrillation yields an unsatisfactorily high number of failures. The hybrid approach has recently emerged as a technique that overcomes the limitations of both surgical and catheter procedures alone. Methods and Results We investigated the sequential (staged) hybrid method, which consists of a surgical thoracoscopic radiofrequency ablation procedure followed by radiofrequency catheter ablation 6 to 8 weeks later using the CARTO 3 mapping system. Fifty consecutive patients (mean age 62±7 years, 32 males) with long‐standing Persistent Atrial Fibrillation (41±34 months) and a dilated left atrium (>45 mm) were included and prospectively followed in an unblinded registry. During the electrophysiological part of the study, all 4 pulmonary veins were found to be isolated in 36 (72%) patients and a complete box‐lesion was confirmed in 14 (28%) patients. All gaps were successfully re‐ablated. Twelve months after the completed hybrid ablation, 47 patients (94%) were in normal sinus rhythm (4 patients with paroxysmal Atrial Fibrillation required propafenone and 1 patient underwent a redo catheter procedure). The majority of arrhythmias recurred during the first 3 months. Beyond 12 months, there were no arrhythmia recurrences detected. The surgical part of the procedure was complicated by 7 (13.7%) major complications, while no serious adverse events were recorded during the radiofrequency catheter part of the procedure. Conclusions The staged hybrid epicardial–endocardial treatment of long‐standing Persistent Atrial Fibrillation seems to be extremely effective in maintenance of normal sinus rhythm compared to radiofrequency catheter or surgical ablation alone. Epicardial ablation alone cannot guarantee durable transmural lesions. Clinical Trial Registration URL: www.ablace.cz Unique identifier: cz‐060520121617
Hugh Calkins - One of the best experts on this subject based on the ideXlab platform.
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Persistent Atrial Fibrillation; It is time to regroup
Journal of cardiovascular electrophysiology, 2019Co-Authors: Ali R. Keramati, Hugh CalkinsAbstract:Pulmonary vein isolation (PVI) is the only proven ablation strategy for paroxysmal and Persistent Atrial Fibrillation (AF). However, when AF recurs despite durable PVI in a subgroup of patients with Persistent AF, there is no scientifically proven ablation strategy to pursue. Here, we summarized how we approach Persistent AF at Johns Hopkins Hospital.
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Phased RF ablation in Persistent Atrial Fibrillation
Heart rhythm, 2013Co-Authors: John D. Hummel, Gregory F. Michaud, Robert H. Hoyt, David B. Delurgio, Abdi Rasekh, Fred Kusumoto, Michael C. Giudici, Dan Dan, David Tschopp, Hugh CalkinsAbstract:Background Persistent and long-standing Persistent Atrial Fibrillation (AF) often requires extensive and/or repeat radiofrequency (RF) ablation procedures. Objective The Tailored Treatment of Persistent Atrial Fibrillation (TTOP-AF) study assessed the effectiveness and safety of the phased RF system in a randomized controlled comparison of medical therapy against phased RF ablation for the management of Persistent and long-standing Persistent AF. Methods Patients who had failed at least 1 antiarrhythmic drug (AAD) were randomized (2:1) to ablation management (AM) or medical management (MM). AM patients were allowed up to 2 ablations. Index and retreatment procedures consisted of pulmonary vein isolation and ablation of complex fractionated Atrial electrograms. MM patients received AAD changes and/or cardioversion. The primary end points of the TTOP-AF study included chronic effectiveness and safety at 6 months and acute safety within 7 days of ablation. Results At 6 months, a greater proportion of AM patients achieved effectiveness off AAD (77 of 138 [55.8%]) compared to MM patients (19 of 72 [26.4%]) (P Conclusions Catheter ablation of Persistent/long-standing Persistent AF with the phased RF ablation system is effective with greater reduction of AF compared with MM. More intense anticoagulation strategies, careful attention to catheter placement relative to the pulmonary vein ostia, and elimination of electrode interaction are expected to reduce the risk of stroke, pulmonary vein stenosis, and asymptomatic cerebral emboli.
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Catheter Ablation of Long Standing Persistent Atrial Fibrillation: Lessons Learned.
Journal of atrial fibrillation, 2013Co-Authors: Obiora Anusionwu, Hugh CalkinsAbstract:Atrial Fibrillation has evolved from being a novel unproven procedure to being an important treatment option for patients with symptomatic Atrial Fibrillation. Atrial Fibrillation ablation is an appropriate treatment option for patients with symptomatic Atrial Fibrillation, particularly if they have failed one or more trials of antiarrhythmic drug therapy. While much has been learned about the optimal technique and outcomes for catheter ablation of paroxysmal Atrial Fibrillation; catheter ablation of Atrial Fibrillation in patients with long standing Persistent Atrial Fibrillation remains in its infancy. The following objectives would be accomplished in this review article. First, we will review the various ablation strategies, which have been employed and proposed for ablation of long standing Persistent Atrial Fibrillation. Second, the methodology, results and outcomes of the major studies were reviewed in detail, which have reported outcomes of ablation in this patient population. And finally, some conclusions were drawn regarding where we stand and where the knowledge gaps remain as we seek to improve ablation outcomes in this population of AF patients.
Vojtech Kurfirst - One of the best experts on this subject based on the ideXlab platform.
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Delayed Electroanatomic Mapping After Surgical Ablation for Persistent Atrial Fibrillation.
The Annals of thoracic surgery, 2017Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech KurfirstAbstract:Background Long-term efficacy of catheter-based treatment of Persistent Atrial Fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently but their true efficacy has never been systematically tested. Methods Seventy patients (median age 63.5 years) with Persistent Atrial Fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein (PV) isolation, linear ablation, Marshal ligament disruption, and exclusion of the left Atrial appendage. The procedure was followed by electroanatomic mapping 2 to 3 months later. Results Only 76% of patients were in sinus rhythm at the beginning of electroanatomic mapping. Right PVs were found isolated in a higher proportion of patients compared with left PVs (75.7% versus 91.4%, p Conclusions Epicardial PV isolation was successful in the majority of patients, but was underwhelming with regard to isolation of the left PVs. Effective epicardially placed linear lines were rare. Our results highlight the significant limitations associated with a single-stage surgical approach and underline the necessity for a two-staged hybrid approach in the treatment of Persistent Atrial Fibrillation.
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Correlates of Arrhythmia Recurrence After Hybrid Epi- and Endocardial Radiofrequency Ablation for Persistent Atrial Fibrillation
Circulation. Arrhythmia and electrophysiology, 2017Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech Kurfirst, Jiri Hanis, Martin Eisenberger, Ladislav DušekAbstract:Background—Long-term efficacy of catheter-based treatment of Persistent Atrial Fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently, but thei...
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Sequential Hybrid Procedure for Persistent Atrial Fibrillation
Journal of the American Heart Association, 2015Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech Kurfirst, Jiri Hanis, Martin Eisenberger, Ladislav PešlAbstract:Background Catheter ablation of Persistent Atrial Fibrillation yields an unsatisfactorily high number of failures. The hybrid approach has recently emerged as a technique that overcomes the limitations of both surgical and catheter procedures alone. Methods and Results We investigated the sequential (staged) hybrid method, which consists of a surgical thoracoscopic radiofrequency ablation procedure followed by radiofrequency catheter ablation 6 to 8 weeks later using the CARTO 3 mapping system. Fifty consecutive patients (mean age 62±7 years, 32 males) with long‐standing Persistent Atrial Fibrillation (41±34 months) and a dilated left atrium (>45 mm) were included and prospectively followed in an unblinded registry. During the electrophysiological part of the study, all 4 pulmonary veins were found to be isolated in 36 (72%) patients and a complete box‐lesion was confirmed in 14 (28%) patients. All gaps were successfully re‐ablated. Twelve months after the completed hybrid ablation, 47 patients (94%) were in normal sinus rhythm (4 patients with paroxysmal Atrial Fibrillation required propafenone and 1 patient underwent a redo catheter procedure). The majority of arrhythmias recurred during the first 3 months. Beyond 12 months, there were no arrhythmia recurrences detected. The surgical part of the procedure was complicated by 7 (13.7%) major complications, while no serious adverse events were recorded during the radiofrequency catheter part of the procedure. Conclusions The staged hybrid epicardial–endocardial treatment of long‐standing Persistent Atrial Fibrillation seems to be extremely effective in maintenance of normal sinus rhythm compared to radiofrequency catheter or surgical ablation alone. Epicardial ablation alone cannot guarantee durable transmural lesions. Clinical Trial Registration URL: www.ablace.cz Unique identifier: cz‐060520121617
Aleš Mokráček - One of the best experts on this subject based on the ideXlab platform.
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Delayed Electroanatomic Mapping After Surgical Ablation for Persistent Atrial Fibrillation.
The Annals of thoracic surgery, 2017Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech KurfirstAbstract:Background Long-term efficacy of catheter-based treatment of Persistent Atrial Fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently but their true efficacy has never been systematically tested. Methods Seventy patients (median age 63.5 years) with Persistent Atrial Fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein (PV) isolation, linear ablation, Marshal ligament disruption, and exclusion of the left Atrial appendage. The procedure was followed by electroanatomic mapping 2 to 3 months later. Results Only 76% of patients were in sinus rhythm at the beginning of electroanatomic mapping. Right PVs were found isolated in a higher proportion of patients compared with left PVs (75.7% versus 91.4%, p Conclusions Epicardial PV isolation was successful in the majority of patients, but was underwhelming with regard to isolation of the left PVs. Effective epicardially placed linear lines were rare. Our results highlight the significant limitations associated with a single-stage surgical approach and underline the necessity for a two-staged hybrid approach in the treatment of Persistent Atrial Fibrillation.
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Correlates of Arrhythmia Recurrence After Hybrid Epi- and Endocardial Radiofrequency Ablation for Persistent Atrial Fibrillation
Circulation. Arrhythmia and electrophysiology, 2017Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech Kurfirst, Jiri Hanis, Martin Eisenberger, Ladislav DušekAbstract:Background—Long-term efficacy of catheter-based treatment of Persistent Atrial Fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently, but thei...
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Sequential Hybrid Procedure for Persistent Atrial Fibrillation
Journal of the American Heart Association, 2015Co-Authors: Alan Bulava, Aleš Mokráček, Vojtech Kurfirst, Jiri Hanis, Martin Eisenberger, Ladislav PešlAbstract:Background Catheter ablation of Persistent Atrial Fibrillation yields an unsatisfactorily high number of failures. The hybrid approach has recently emerged as a technique that overcomes the limitations of both surgical and catheter procedures alone. Methods and Results We investigated the sequential (staged) hybrid method, which consists of a surgical thoracoscopic radiofrequency ablation procedure followed by radiofrequency catheter ablation 6 to 8 weeks later using the CARTO 3 mapping system. Fifty consecutive patients (mean age 62±7 years, 32 males) with long‐standing Persistent Atrial Fibrillation (41±34 months) and a dilated left atrium (>45 mm) were included and prospectively followed in an unblinded registry. During the electrophysiological part of the study, all 4 pulmonary veins were found to be isolated in 36 (72%) patients and a complete box‐lesion was confirmed in 14 (28%) patients. All gaps were successfully re‐ablated. Twelve months after the completed hybrid ablation, 47 patients (94%) were in normal sinus rhythm (4 patients with paroxysmal Atrial Fibrillation required propafenone and 1 patient underwent a redo catheter procedure). The majority of arrhythmias recurred during the first 3 months. Beyond 12 months, there were no arrhythmia recurrences detected. The surgical part of the procedure was complicated by 7 (13.7%) major complications, while no serious adverse events were recorded during the radiofrequency catheter part of the procedure. Conclusions The staged hybrid epicardial–endocardial treatment of long‐standing Persistent Atrial Fibrillation seems to be extremely effective in maintenance of normal sinus rhythm compared to radiofrequency catheter or surgical ablation alone. Epicardial ablation alone cannot guarantee durable transmural lesions. Clinical Trial Registration URL: www.ablace.cz Unique identifier: cz‐060520121617