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Nakhla M, Ahmed MS, Bishara R, Iskandar O, Raju AKV, Frishman WH, Aronow WS. Incidence, Mechanism, and Management of Atrial Ablation Procedure Complications: A Literature Review. Cardiol Rev 2024:00045415-990000000-00392. [PMID: 39760995 DOI: 10.1097/crd.0000000000000842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2025]
Abstract
The number of atrial catheter ablation procedures has significantly increased in recent years, becoming a first-line treatment modality for various supraventricular tachycardias due to their safety and efficacy. Complications, ranging from mild to life-threatening, can arise during different stages of the procedure, including vascular access complications (eg, hematoma or vascular fistula formation, retroperitoneal bleeding, etc.), thromboembolic complications (eg, stroke, transient ischemic attack, air embolism, etc.), mechanical complications (eg, cardiac perforation and tamponade), as well as pulmonary vein stenosis, atrio-esophageal fistulas, phrenic nerve injury, and gastroparesis. Atrial fibrillation ablation procedures, in particular, carry a higher complication rate due to their complexity. This review discusses the incidence, mechanisms, diagnosis, management, and prevention of these complications. Key strategies to reduce risks include optimized anticoagulation protocols, the use of intracardiac echocardiography, reduced energy delivery, and esophageal temperature monitoring, among others. Timely detection and intervention, especially in the case of life-threatening complications, is crucial. Pulsed-field ablation, a novel technique using nonthermal electrical energy, offers a promising and precise alternative to conventional thermal ablation with a favorable safety profile. However, further research is needed to fully understand its complications and refine management strategies.
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Affiliation(s)
- Michael Nakhla
- From the Department of Medicine, Saint Vincent Hospital, Worcester, MA
| | - Mahmoud Samy Ahmed
- Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Rafik Bishara
- Department of Cardiology, National Heart Institute, Cairo, Egypt
| | - Odette Iskandar
- Department of Medicine, Salem Hospital, Mass General Brigham, Salem, MA, and
| | | | | | - Wilbert S Aronow
- Departments of Cardiology and Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY
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Karatela MF, Dowell RS, Friedman DJ, Jackson KP, Thomas KL, Piccini JP. Peak frequency mapping of atypical atrial flutter. J Cardiovasc Electrophysiol 2024; 35:950-964. [PMID: 38477184 DOI: 10.1111/jce.16221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Peak frequency (PF) mapping is a novel method that may identify critical portions of myocardial substrate supporting reentry. The aim of this study was to describe and evaluate PF mapping combined with omnipolar voltage mapping in the identification of critical isthmuses of left atrial (LA) atypical flutters. METHODS AND RESULTS LA omnipolar voltage and PF maps were generated in flutter using the Advisor HD-Grid catheter (Abbott) and EnSite Precision Mapping System (Abbott) in 12 patients. Normal voltage was defined as ≥0.5 mV, low-voltage as 0.1-0.5 mV, and scar as <0.1 mV. PF distributions were compared with ANOVA and post hoc Tukey analyses. The 1 cm radius from arrhythmia termination was compared to global myocardium with unpaired t-testing. The mean age was 65.8 ± 9.7 years and 50% of patients were female. Overall, 34 312 points were analyzed. Atypical flutters most frequently involved the mitral isthmus (58%) or anterior wall (25%). Mean PF varied significantly by myocardial voltage: normal (335.5 ± 115.0 Hz), low (274.6 ± 144.0 Hz), and scar (71.6 ± 140.5 Hz) (p < .0001 for all pairwise comparisons). All termination sites resided in low-voltage regions containing intermediate or high PF. Overall, mean voltage in the 1 cm radius from termination was significantly lower than the remaining myocardium (0.58 vs. 0.95 mV, p < .0001) and PF was significantly higher (326.4 vs. 245.1 Hz, p < .0001). CONCLUSION Low-voltage, high-PF areas may be critical targets during catheter ablation of atypical atrial flutter.
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Affiliation(s)
- Maham F Karatela
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Robert S Dowell
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
- Abbott, St. Paul, Minnesota, USA
| | - Daniel J Friedman
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kevin P Jackson
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin L Thomas
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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Hara S, Miwa N, Kusa S, Sato Y, Doi J, Nakata T, Hirano H, Ishizawa T, Hachiya H. Conduction time around the mitral valve annulus has the potential to rule out postablation perimitral atrial tachycardia. J Cardiovasc Electrophysiol 2024; 35:348-359. [PMID: 38180129 DOI: 10.1111/jce.16166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION It would be helpful in determining ablation strategy if the occurrence of perimitral atrial tachycardia (PMAT) could be predicted in advance. We investigated whether estimated perimitral conduction time (E-PMCT), namely, twice the time between coronary sinus (CS) pacing and the ensuing wave-front collision at the opposite side of the mitral annulus, correlated with the cycle length of PMAT and could predict future PMAT. METHODS AND RESULTS We retrospectively (retrospective cohort) and prospectively (validation cohort) investigated atrial fibrillation patients who had received pulmonary vein isolation (PVI) and in whom left atrial maps had been created during CS pacing. We calculated their E-PMCT. PMAT was observed either by provocation or during follow-up in 25, AT other than PMAT was observed in 24 (non-PMAT AT group), and 53 patients never displayed any AT (no-AT group) in the retrospective cohort. In the PMAT group of the retrospective cohort, a strong positive correlation was observed between the PMAT CL and E-PMCT (r = .85, p < 0.001). PMAT was never induced nor observed in patients with E-PMCT less than 176 ms, and the best cut-off value for PMAT was 180 ms by receiver-operating characteristic curve analysis. In the validation cohort of 76 patients, the cut-off value of the E-PMAT less than 180 ms predicted noninducibility of PMAT, with a sensitivity of 78.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 25.0%. CONCLUSION Short E-PMCT may predict noninducibility of PMAT and guide a less invasive ablation strategy.
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Affiliation(s)
- Satoshi Hara
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Naoyuki Miwa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Shigeki Kusa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Yoshikazu Sato
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Junichi Doi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Tadanori Nakata
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Hidenori Hirano
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Taiki Ishizawa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
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Yu SD, Chu YP. Identification of the dominant loop of a dual-loop macro-reentry left atrial flutter without prior intervention using high-density mapping technology: A case report. World J Clin Cases 2023; 11:6165-6169. [PMID: 37731554 PMCID: PMC10507564 DOI: 10.12998/wjcc.v11.i26.6165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/31/2023] [Accepted: 08/11/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Left atrial flutter without prior cardiac interventions is uncommon, especially dual-loop macro-reentry atrial flutter. The critical step to ablate dual-loop macro-reentry atrial flutter is to identify the dominant loop and key isthmus. Although entrainment mapping could help identify the dominant loop and key isthmus, it may alter or terminate tachycardia. High-density mapping allows the generation of electroanatomic maps without altering or terminating tachycardia. CASE SUMMARY Here, we report a case of symptomatic left atrial flutter without prior intervention. In this case, high-density mapping revealed a dual-loop macro-reentry around the mitral annulus and central scar of the anterior wall. The propagation result showed that the dominant loop was around the mitral annulus, and the key isthmus was between the central scar and mitral annulus. The atrial flutter terminated successfully after ablation was performed. CONCLUSION In this case, we demonstrate that high-density mapping technology may help identify the dominant loop of dual-loop atrial flutter without entrainment, which makes ablation easier.
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Affiliation(s)
- Shan-Dong Yu
- Department of Cardiology, Capital Medical University affiliated Beijing Friendship Hospital, Beijing 100010, China
| | - Yan-Peng Chu
- Department of Cardiology, Dazhou Central Hospital, Dazhou 635000, Sichuan Province, China
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Masuda M, Inoue K, Tanaka N, Watanabe T, Makino N, Egami Y, Oka T, Minamiguchi H, Miyoshi M, Okada M, Kanda T, Mano T, Matsuda Y, Uematsu H, Sakio T, Kawasaki M, Sunaga A, Sotomi Y, Dohi T, Nakatani D, Hikoso S, Sakata Y, the Osaka Cardiovascular Conference (OCVC)‐Arrhythmia Investigators. Long-Term Impact of Additional Ablation After Pulmonary Vein Isolation: Results From EARNEST-PVI Trial. J Am Heart Assoc 2023; 12:e029651. [PMID: 37642022 PMCID: PMC10547359 DOI: 10.1161/jaha.123.029651] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/30/2023] [Indexed: 08/31/2023]
Abstract
Background An optimal strategy for left atrial ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not been determined. Methods and Results We conducted an extended follow-up of the multicenter randomized controlled EARNEST-PVI (Efficacy of Pulmonary Vein Isolation Alone in Patients With Persistent Atrial Fibrillation) trial, which compared 12-month rhythm outcomes in patients with persistent AF between patients randomized to a PVI-alone strategy (n=248) or PVI-plus strategy (n=248; PVI followed by left atrial additional ablation, including linear ablation or ablation targeting areas with complex fractionated electrograms). The present study extended the follow-up period to 3 years after enrollment. Outcomes were compared not only between randomly allocated groups but also between on-treatment groups categorized by actually created ablation lesions. Recurrence rate of AF or atrial tachycardia (AT) was lower in the randomly allocated to PVI-plus group than the PVI-alone group (29.0% versus 37.5%, P=0.036). On-treatment analysis revealed that patients with PVI+linear ablation (n=205) demonstrated a lower AF/AT recurrence rate than those with PVI only (26.3% versus 37.8%, P=0.007). In contrast, patients with PVI+complex fractionated electrograms ablation (n=37) had an AF/AT recurrence rate comparable to that of patients with PVI only (40.5% versus 37.8%, P=0.76). At second ablation in 126 patients with AF/AT recurrence, ATs excluding common atrial flutter were more frequent in patients with PVI+linear ablation than in those with PVI only (32.6% versus 5.7%, P<0.0001). Conclusions Left atrial ablation in addition to PVI was efficacious during 3-year follow-up. Linear ablation was superior to other ablation strategies but may increase iatrogenic ATs. Registration URL: http://www.umin.ac.jp/ctr/index-j.htm; Unique identifier: UMIN000019449.
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Affiliation(s)
| | - Koichi Inoue
- Cardiovascular DivisionNational Hospital Organization Osaka National HospitalOsakaJapan
| | - Nobuaki Tanaka
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | | | | | | | - Takafumi Oka
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
| | | | - Miwa Miyoshi
- Department of CardiologyOsaka Hospital, Japan Community Healthcare OrganizationOsakaJapan
| | - Masato Okada
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Takashi Kanda
- Cardiovascular DivisionOsaka Police HospitalOsakaJapan
| | - Toshiaki Mano
- Cardiovascular CenterKansai Rosai HospitalAmagasakiJapan
| | | | | | | | - Masato Kawasaki
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | - Akihiro Sunaga
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Yohei Sotomi
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Tomoharu Dohi
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Daisaku Nakatani
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Shungo Hikoso
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Yasushi Sakata
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineOsakaJapan
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Hu W, Zhou D, Ding X, Yang G, Liu H, Wang Z, Chen H, Ju W, Li M, Zhang F, Yang J, Han J, Wu X, Qiu Z, Zheng L, Chen M. Arrhythmogenesis of surgical atrial incisions and lesions in Maze procedure: insights from high-resolution mapping of atrial tachycardias. Europace 2023; 25:137-145. [PMID: 35851635 PMCID: PMC10112846 DOI: 10.1093/europace/euac102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Atrial tachycardias (ATs) frequently develop after a surgical Maze procedure. We aimed to elucidate the electrophysiologic mechanisms and their arrhythmogenic substrates of these ATs. METHODS AND RESULTS We retrospectively reviewed 20 patients (14 females, mean age of 55.5 ± 8.6 years) with post-Maze ATs who underwent high-resolution mapping at three institutions. The slow conduction areas, reentry circuits, voltage signals, complex electrograms, and their correlation with the surgical incisions and lesions placed in the surgical Maze procedures were analyzed. Thirty-six ATs with a mean cycle length of 260.0 ± 67.6 ms were mapped in these patients. Among them, 22 (61.1%) were anatomical macro-reentrant ATs (AMAT), 12 (33.3%) non-AMATs (localized ATs), and 2 (5.6%) focal ATs, respectively. Epicardial conduction bridges were observed in 6/20 (30.0%) patients and 7/36 (19.4%) ATs. Different arrhythmogenic substrates were identified in these ATs, including slow conduction regions within the previous lesion areas or between the incisions and anatomical structures, the prolonged activation pathways caused by the short lesions connecting the tricuspid annulus, and the circuits around the long incisions and/or lesions. CONCLUSIONS Reentry is the main mechanism of the post-Maze ATs. The pro-arrhythmic substrates are most likely caused by surgical incisions and lesions. The slow conduction regions and the protected channels yielded from these areas are the major arrhythmogenic factors.
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Affiliation(s)
- Wei Hu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dongchen Zhou
- Cardiology Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiangwei Ding
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hailei Liu
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zidun Wang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizu Ju
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingfang Li
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jian Yang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Han
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xianhao Wu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaohui Qiu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liangrong Zheng
- Cardiology Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Minglong Chen
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Cardiology Department, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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7
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Gao MY, Sang CH, Huang LH, Lai YW, Guo Q, Liu XX, Zuo S, Li CY, Wang W, Guo XY, Zhao X, Li SN, Jiang CX, Liu N, Tang RB, Du X, Long DY, Dong JZ, Ma CS. Vein of Marshall ethanol infusion: First-step or adjunctive choice for perimitral atrial tachycardia? Pacing Clin Electrophysiol 2023; 46:20-30. [PMID: 36401609 DOI: 10.1111/pace.14617] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/23/2022] [Accepted: 11/01/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Perimitral atrial tachycardia (PMAT) is the most frequent type of iatrogenic atrial tachycardia (AT) after atrial fibrillation (AF) ablation. Vein of Marshall ethanol infusion (EIVOM) is a promising technique in mitral isthmus (MI) ablation. METHODS A total of 165 patients with PMAT were divided into three groups according to ablation strategies, including RF only group (n = 89), RF-EIVOM group (initial RF ablation with adjunctive EIVOM, n = 28), and EIVOM-RF group (first-step EIVOM with touch-up RF ablation, n = 48). Acute and follow-up procedure outcomes were evaluated. RESULTS PMAT terminated in 89.9%, 89.3%, and 93.7% of patients in RF only, RF-EIVOM and EIVOM-RF groups, respectively (p = .715), with complete MI block achieved in 80.9%, 89.3%, and 95.8% of patients (EIVOM-RF vs. RF only, p = .012). First-step utilization of EIVOM was associated with a significant shortening of RF ablation time at MI (EIVOM-RF 2.1 ± 1.3 min, RF only 7.9 ± 5.9 min, RF-EIVOM 6.8 ± 5.8 min; p < .001) and a decrease in the proportion of patients need ablation within coronary sinus (CS, EIVOM-RF 14.6%, RF only 61.8%, RF-EIVOM 64.3%; p < .001). After a mean follow-up of 12.1 ± 6.2 months, AF/AT recurred in 39 (43.8%), 6 (21.4%), and 12 (25.0%) patients in RF only, RF-EIVOM, and EIVOM-RF group (RF-EIVOM vs. RF only, p = .026; EIVOM-RF vs. RF only, p = .022). CONCLUSIONS EIVOM was associated with an enhanced acute MI block rate as well as reduced AF/AT recurrence. First-step utilization of EIVOM promises to significantly simplify the RF ablation process. CONDENSED ABSTRACT PMAT is the most common type of iatrogenic AT after AF ablation procedures. EIVOM contributed to a higher acute MI block rate and lower arrhythmia recurrence risk during follow-up. First-step utilization of EIVOM significantly reduced the need for radiofrequency ablation at MI and inside CS with the advantage of creating a homogenous, transmural lesion and eliminating epicardial connections.
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Affiliation(s)
- Ming-Yang Gao
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Li-Hong Huang
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Yi-Wei Lai
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Qi Guo
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Xiao-Xia Liu
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Song Zuo
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Chang-Yi Li
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Wei Wang
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Xue-Yuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Xin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Song-Nan Li
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Chen-Xi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - De-Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, National Clinical Research Centre for Cardiovascular Diseases, Capital Medical University, Beijing, China
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Pott A, Teumer Y, Weinmann K, Baumhardt M, Schweizer C, Buckert D, Bothner C, Rottbauer W, Dahme T. Substrate-based ablation of atypical atrial flutter in patients with atrial cardiomyopathy. IJC HEART & VASCULATURE 2022; 40:101018. [PMID: 35495579 PMCID: PMC9043977 DOI: 10.1016/j.ijcha.2022.101018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/12/2022] [Accepted: 03/25/2022] [Indexed: 12/03/2022]
Abstract
Background Standard therapy of atypical atrial flutter (AFL) aims at deploying ablation lines between two non-conducting anatomical structures, thereby creating a line of block within the re-entry circuit. We have developed an ablation strategy, where we incorporate voltage information as a surrogate for atrial fibrosis from the electro-anatomical map (EAM) during AFL ablation procedures to create individualized, substrate-based ablation lines along the area of most pronounced low-voltage within the reentry-circuit. Objective The aim of this study was to evaluate acute procedural success and long-term outcome of a substrate-based ablation (SBA) strategy in comparison to a standard anatomically based ablation (ABA) strategy for the ablation of atypical AFL. Methods Patients that underwent ablation for AFL at our institution were included. SBA procedures were compared to ABA procedures. Endpoints were acute termination of AFL and recurrence of the index AFL or any other AFL during follow-up. Results We included 47 patients, 24 individuals (51.1%) in the SBA group and 23 patients (48.9%) in the ABA group. Most patients had signs of atrial cardiomyopathy, namely enlarged left atrial diameter (LAD) and extended amount of left atrial low-voltage areas (LVA). Termination of AFL occurred in 27 of 29 (93.1%) AFL in the SBA group and in 28 of 31 (90.3%) AFL in the ABA group (p = 0.99). Freedom from recurrence of any atypical AFL after 2.5 years was 21.5% in the ABA group compared to 48.8% in the SBA group (p = 0.047). Conclusion Substrate-based ablation is as effective as an anatomically-based ablation in the acute termination of AFL but yields better rhythm outcome with less recurrence of AFL in patients with atrial cardiomyopathy.
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9
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Comparison of the Anterior Septal Line and Mitral Isthmus Line for Perimitral Atrial Flutter Ablation Using Robotic Magnetic Navigation. J Interv Cardiol 2022; 2022:1793590. [PMID: 35185396 PMCID: PMC8826208 DOI: 10.1155/2022/1793590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/13/2021] [Accepted: 01/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Perimitral atrial flutter (PMAFL) is one of the most common macro-reentrant left atrial tachycardias. Mitral isthmus (MI) linear ablation is a common strategy for the treatment of PMAFLs, and anterior septum (AS) linear ablation has emerged as a novel ablation approach. We aimed at assessing the effectiveness of AS linear ablation using robotic magnetic navigation for PMAFL ablation. Methods In this retrospective study, a total of 36 consecutive patients presented with AFL as the unique arrhythmia or accompanied with atrial fibrillation (AF) who underwent catheter ablation were enrolled. Patients were classified into two groups according to the different ablation strategies, the MI line group (10 patients) and the AS line group (26 patients). Results The clinical baseline characteristics of patients in the two groups were nearly identical. There were no significant differences in procedure time (148.7 ± 46.1 vs. 123.2 ± 30.1 min, P=0.058) or radiofrequency ablation time (25.9 ± 11.4 vs. 23.5 ± 12.6 min) between the two groups. Fluoroscopy time was longer in the MI line group (8.0 ± 4.4 vs. 5.1 ± 2.7 min, P=0.024), and the acute success rate was higher in the AS line group versus the MI line group (96.2% vs. 70%, P=0.025). The long-term freedom from arrhythmia survival rate was higher in the AS line group (73%) than in the MI line group (40%) after a mean follow-up time of 37.4 months with a 3-month blanking period (P=0.049). Conclusions AS linear ablation is an effective and safe strategy for PMAFL ablation using robotic magnetic navigation.
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10
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An Y, Ogawa H, Yanagisawa M, Marumiya C, Ikeda S, Akao M. Single-loop bi-atrial tachycardia with presumed conduction block across an anteroseptal mitral ablation line: A case report: Bi-AT after septal mitral isthmus ablation. J Cardiol Cases 2021; 24:89-93. [PMID: 34354785 DOI: 10.1016/j.jccase.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/31/2021] [Accepted: 02/04/2021] [Indexed: 11/29/2022] Open
Abstract
A 64-year-old man with no previous medical history underwent catheter ablation (CA) by right pulmonary vein isolation and creation of an anteroseptal mitral isthmus (MI) line for peri-mitral atrial flutter. Since atrial tachycardia (AT) recurred with palpitation 4 months later, a second CA session was performed. Although the differential pacing method appeared to confirm the conduction block across the MI line previously created, single-loop bi-atrial AT (Bi-AT) involving both atria through the septum was induced. When the upper septum of the right atrium was ablated, Bi-AT was terminated. Of note, the time from the onset of the P-wave to activation of the left atrial appendage increased after the ablation compared to before. Learning objective: The anteroseptal mitral isthmus line between the right superior pulmonary vein and the septal mitral annulus is an effective therapy for peri-mitral atrial flutter. However, there are some problems such as difficulty in assessing the bidirectional block of this line and the occurrence of bi-atrial tachycardia via the Bachmann bundle. Further investigation needs to clarify whether conduction block of this interatrial bundle is an appropriate endpoint, as the clinical impacts of conduction delay of left atrial appendage remain uncertain. <Learning objective: The anteroseptal mitral isthmus line between the right superior pulmonary vein and the septal mitral annulus is an effective therapy for peri-mitral atrial flutter However, there are some problems such as difficulty in assessing the bidirectional block of this line and the occurrence of biatrial atrial tachycardia via the Bachmann bundle. Further investigation needs to clarify whether conduction block of this interatrial bundle is an appropriate endpoint as the clinical impacts of conduction delay of left atrial appendage remain uncertain.>.
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Affiliation(s)
- Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masami Yanagisawa
- Department of Clinical Engineering, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Chifuyu Marumiya
- Department of Clinical Engineering, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Syuhei Ikeda
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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11
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Markowitz SM. Detecting Critical Channels in Perimitral Flutter: Will Ripple Mapping Make a Splash? JACC Clin Electrophysiol 2021; 7:591-593. [PMID: 34016390 DOI: 10.1016/j.jacep.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/09/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Steven M Markowitz
- Division of Cardiology, Department of Medicine, Weill Cornell Medical Center, New York, New York, USA.
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12
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Katritsis G, Luther V, Cortez-Dias N, Carpinteiro L, de Sousa J, Lim PB, Whinnett Z, Ng FS, Koa-Wing M, Qureshi N, Chow A, Agarwal S, Jamil-Copley S, Peters NS, Linton N, Kanagaratnam P. Electroanatomic Characterization and Ablation of Scar-Related Isthmus Sites Supporting Perimitral Flutter. JACC Clin Electrophysiol 2021; 7:578-590. [PMID: 33516707 DOI: 10.1016/j.jacep.2020.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/24/2020] [Accepted: 10/24/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The authors reviewed 3-dimensional electroanatomic maps of perimitral flutter to identify scar-related isthmuses and determine their effectiveness as ablation sites. BACKGROUND Perimitral flutter is usually treated by linear ablation between the left lower pulmonary vein and mitral annulus. Conduction block can be difficult to achieve, and recurrences are common. METHODS Patients undergoing atrial tachycardia ablation using CARTO3 (Biosense Webster Inc., Irvine, California) were screened from 4 centers. Patients with confirmed perimitral flutter were reviewed for the presence of scar-related isthmuses by using CARTO3 with the ConfiDense and Ripple Mapping modules. RESULTS Confirmed perimitral flutter was identified in 28 patients (age 65.2 ± 8.1 years), of whom 26 patients had prior atrial fibrillation ablation. Scar-related isthmus ablation was performed in 12 of 28 patients. Perimitral flutter was terminated in all following correct identification of a scar-related isthmus using ripple mapping. The mean scar voltage threshold was 0.11 ± 0.05 mV. The mean width of scar-related isthmuses was 8.9 ± 3.5 mm with a conduction speed of 31.8 ± 5.5 cm/s compared to that of normal left atrium of 71.2 ± 21.5 cm/s (p < 0.0001). Empirical, anatomic ablation was performed in 16 of 28, with termination in 10 of 16 (63%; p = 0.027). Significantly less ablation was required for critical isthmus ablation compared to empirical linear lesions (11.4 ± 5.3 min vs. 26.2 ± 17.1 min; p = 0.0004). All 16 cases of anatomic ablation were reviewed with ripple mapping, and 63% had scar-related isthmus. CONCLUSIONS Perimitral flutter is usually easy to diagnose but can be difficult to ablate. Ripple mapping is highly effective at locating the critical isthmus maintaining the tachycardia and avoiding anatomic ablation lines. This approach has a higher termination rate with less radiofrequency ablation required.
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Affiliation(s)
| | | | | | | | | | | | | | - Fu Siong Ng
- Imperial College Healthcare, London, United Kingdom
| | | | | | | | | | | | | | - Nick Linton
- Imperial College Healthcare, London, United Kingdom
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13
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赵 海, 谭 振, 何 利, 朱 世, 颜 如, 寇 宏, 彭 健. [Amiodarone promotes heat-induced apoptosis, inflammation and oxidative stress in mouse HL1 atrial myocytes]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2021; 41:406-411. [PMID: 33849832 PMCID: PMC8075778 DOI: 10.12122/j.issn.1673-4254.2021.03.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the injury types of atrial myocytes induced by heat exposure and the effect of amiodarone on heat-induced injuries in atrial myocytes. OBJECTIVE The optimal temperature for heat exposure and optimal concentration of amiodarone were determined by measuring the cell viability exposed to different temperatures and different concentrations of amiodarone. Heat exposure of HL1 atrial myocytes was conducted using a water bath, and the effect of amiodarone on cell viability was assessed with MTS method; cell apoptosis was detected using flow cytometry, and the levels of IL-1β, IL-6, TNF-α, SOD and MDA were detected with enzyme-linked immunosorbent assay (ELISA). OBJECTIVE Compared with the blank control cells, the cells exposed to a temperature of 52 ℃ showed a significantly decreased survival rate and a lowered SOD activity (P < 0.001) with increased IL-1β and MDA levels (P < 0.01) and markedly increased apoptosis rate and IL-6 level (P < 0.001). Compared with the heat exposure group, amiodarone resulted in significantly decreased survival rate of the atrial myocytes (P < 0.01), obviously decreased SOD activity (P < 0.05), and increased cell apoptosis rate (P < 0.05) and IL-1β, IL-6, MDA and TNF-α levels (P < 0.01 or 0.001). OBJECTIVE Heat exposure induces apoptosis, inflammation and oxidative stress in mouse HL1 atrial myocytes, and amiodarone can enhance the effects of heat exposure to aggravate the cell injuries.
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Affiliation(s)
- 海玉 赵
- />南方医科大学南方医院心血管内科，广东 广州 510515Department of Cardiovascular Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 振林 谭
- />南方医科大学南方医院心血管内科，广东 广州 510515Department of Cardiovascular Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 利伟 何
- />南方医科大学南方医院心血管内科，广东 广州 510515Department of Cardiovascular Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 世杰 朱
- />南方医科大学南方医院心血管内科，广东 广州 510515Department of Cardiovascular Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 如玉 颜
- />南方医科大学南方医院心血管内科，广东 广州 510515Department of Cardiovascular Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 宏强 寇
- />南方医科大学南方医院心血管内科，广东 广州 510515Department of Cardiovascular Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 健 彭
- />南方医科大学南方医院心血管内科，广东 广州 510515Department of Cardiovascular Diseases, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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14
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Hu W, Zhou D, Hua B, Yang G, Chen H, Ju W, Li M, Zhang F, Zheng L, Chen M. Flutter Wave Morphology of Peri-Mitral Atrial Flutters Is Mainly Determined by Right Atrial Activation: Insights From High-Resolution Mapping. Circ Arrhythm Electrophysiol 2020; 13:e008446. [PMID: 32718185 DOI: 10.1161/circep.120.008446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Peri-mitral atrial flutters frequently develop post-atrial fibrillation ablation or postcardiac surgery. The determinants of the flutter wave morphology on surface ECG have been less studied. METHODS We retrospectively reviewed 24 patients with peri-mitral atrial flutters who underwent biatrial high-resolution mapping at 3 institutions with LUMIPOINT software. We analyzed the overlap between the right atrial (RA) activation time and flutter wave duration and compared the proportion of the endocardial area that was activated in both atria during the flutter wave duration. Biatrial activation patterns and interatrial conductions were also identified. RESULTS The mean tachycardia cycle length was 264±60 ms, with RA activation time 155±45 ms (60.8±20.6% of the tachycardia cycle length), and the flutter wave duration 107±31 ms (41.6±11.7% of the tachycardia cycle length). The overlap between the RA activation time and the flutter wave duration was 102±29 ms, which takes 68.5±17.2% of the RA activation time and 95.7±9.1% of the flutter wave duration, respectively. Quantitative analysis also showed that during the flutter wave duration, more percentage of the endocardial area was activated in the RA than in the left atrium (73.0±12.7% versus 45.2±13.0%, P<0.001). We consistently observed that the RA anterior wall rightward activation corresponded to the positive component in V1 in both flutter patterns, and the RA downward activation corresponded to the positive component in the counterclockwise group or the upward activation corresponded to the negative component in the clockwise group in the inferior leads. The passive RA activation patterns were varied with spontaneous atrial scarring or previous linear ablation. CONCLUSIONS ECG flutter wave morphology of peri-mitral atrial flutters is mainly dependent on RA activation patterns.
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Affiliation(s)
- Wei Hu
- The First Affiliated Hospital of Nanjing Medical University, China (W.H., G.Y., H.C., W.J., M.L., F.Z., M.C.)
| | - Dongchen Zhou
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou (D.Z., L.Z.)
| | - Baotong Hua
- First Affiliated Hospital of Kunming Medical University, China (B.H.)
| | - Gang Yang
- The First Affiliated Hospital of Nanjing Medical University, China (W.H., G.Y., H.C., W.J., M.L., F.Z., M.C.)
| | - Hongwu Chen
- The First Affiliated Hospital of Nanjing Medical University, China (W.H., G.Y., H.C., W.J., M.L., F.Z., M.C.)
| | - Weizu Ju
- The First Affiliated Hospital of Nanjing Medical University, China (W.H., G.Y., H.C., W.J., M.L., F.Z., M.C.)
| | - Mingfang Li
- The First Affiliated Hospital of Nanjing Medical University, China (W.H., G.Y., H.C., W.J., M.L., F.Z., M.C.)
| | - Fengxiang Zhang
- The First Affiliated Hospital of Nanjing Medical University, China (W.H., G.Y., H.C., W.J., M.L., F.Z., M.C.)
| | - Liangrong Zheng
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou (D.Z., L.Z.)
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, China (W.H., G.Y., H.C., W.J., M.L., F.Z., M.C.)
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15
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Ouyang F, Maurer T. Choose Your Battles: Catheter Ablation of Perimitral Flutter. JACC Clin Electrophysiol 2019; 5:1300-1302. [PMID: 31753436 DOI: 10.1016/j.jacep.2019.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/11/2019] [Accepted: 10/15/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Feifan Ouyang
- National Center of Cardiovascular Disease and Fuwai Hospital, Beijing Union Medical College and The Chinese Academy of Medical Sciences, Beijing, China.
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16
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Maheshwari A, Shirai Y, Hyman MC, Arkles JS, Santangeli P, Schaller RD, Supple GE, Nazarian S, Lin D, Dixit S, Callans DJ, Marchlinski FE, Frankel DS. Septal Versus Lateral Mitral Isthmus Ablation for Treatment of Mitral Annular Flutter. JACC Clin Electrophysiol 2019; 5:1292-1299. [PMID: 31753435 DOI: 10.1016/j.jacep.2019.08.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study sought to compare efficacy and safety of the septal mitral isthmus line (SMIL) with that of the lateral mitral isthmus line (LMIL) for treatment of mitral annular flutter (MAF). BACKGROUND MAF is the most common left atrial macro-re-entrant organized atrial tachycardia (OAT) occurring after catheter ablation of atrial fibrillation. The 2 most common lesion sets for treating MAF include linear ablation from the anteroseptal mitral annulus to the right superior pulmonary vein (SMIL) and from the lateral mitral annulus to left inferior pulmonary vein (LMIL). METHODS The study included all mitral isthmus ablations performed at the Hospital of the University of Pennsylvania in 2016 and 2017. Acute procedural results and long-term arrhythmia-free survival were compared between groups. RESULTS Of 114 total MILs, conduction block was achieved across 73 (93.6%) SMILs compared with 29 (80.6%) LMILs (p = 0.05). Although the length of the SMIL was longer (48.9 ± 12.8 cm vs. 38.7 ± 12.8 cm; p = 0.001), time required to achieve block was shorter (25.2 ± 15.9 min vs. 36.6 ± 21.3 min; p = 0.03). Coronary sinus ablation was required in 58.3% of LMILs due to inability to achieve conduction block with left atrial ablation alone. In multivariate analysis, only failure to achieve acute MIL block remained significantly associated with subsequent OAT recurrence (hazard ratio: 6.39; 95% confidence interval: 1.37 to 29.9; p = 0.02). CONCLUSIONS The SMIL requires less time to complete and more frequently results in acute MIL block than the LMIL. Additionally, ablation is rarely required outside the left atrium. Failure to achieve acute MIL block is strongly associated with subsequent OAT recurrence.
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Affiliation(s)
- Ankit Maheshwari
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yasuhiro Shirai
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew C Hyman
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Arkles
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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