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Obstructive Events in Sleep Apnoea Causes Acute Atrial Remodelling in Patients with Atrial Fibrillation
S108
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
Conclusion: SubM-ICD implantation in young females is safe with long term system performance that is satisfactory. A clinically insignificant RV pacing threshold rise with decrease in lead impedance was noted.
253 Noncontact Mapping System and CFAE Ablation Add to PVI Get Better for Chronic as AF on the First Session
doi:10.1016/j.hlc.2010.06.918
D. Yuasa ∗ , S. Kaneko, M. Shinoda, H. Kamiya, R. Kubota, Y. Tatami, M. Hayashi, H. Kanayama
252
Toyota Kosei Hospital, Japan
Long-term Outcome Following Ablation of Atrial Arrhythmias Occurring Late After Atrial Septal Defect Repair. High Incidence of Late Atrial Fibrillation
Backgrounds: To modify the atrial fibrillation (AF) substrate, complex fractionated atrial electrogram (CFAE) ablation seems to be effective. But the endpoint of CFAE ablation is unclear because of difficulty of confirming the disappearance of CFAE by usual mapping. Although the benefit of noncontact mapping (NCM) system in chronic AF (CAF) ablation is not validated, the disappearance of CFAE could be effectively confirmed by using NCM system in CAF ablation. Objectives: We evaluated the efficacy of NCM system guided CFAE ablation for CAF patients. Methods: We compared the recurrence rate of AF after catheter ablation in CAF patients who underwent either NCM system guided PVI+CFAE ablation (Group 1), using Laplacian bipolar or pulmonary vein isolation (PVI) + left atrial linear ablation (Group 2). From April 2005 to December 2009, we performed CAF ablation for 33 patients; 18 patients in Group 1 (6 patients underwent both atrial CFAE ablation) and 15 patients in Group 2. There were no significant differences in clinical characteristics between the two groups. Results: Mean follow up period was 9.6 ± 6.2 (Group 1) months vs. 8.0 ± 7.1 (Group 2) months. 77.8% in Group 1 was not AF and 15.4% in Group 2 was not AF after ablation (P < 0.01). Conclusions: AF substrate modification by NCM system guided CFAE ablation got effected in CAF patients.
A. Teh 1,∗ , C. Medi 1 , P. Sparks 1 , P. Kistler 1,2 , G. Lee 1 , J. Morton 1 , J. Vohra 1 , K. Halloran 1 , J. Kalman 1 1 Royal 2 Baker
Melbourne Hospital, Australia IDI Heart and Diabetes Institute, Australia
Background: In patients with surgical atrial septal defect (ASD) repair, late atrial arrhythmias (AAs) including cavo-tricuspid isthmus (CTI)-dependent and non-CTI-dependent scar-related flutter (AFL) are common. Radiofrequency ablation (RFA) of these arrhythmias has a high acute success rate. We aimed to characterize the incidence of late recurrences and late atrial fibrillation (AF) in this population. Methods: 26 consecutive patients with post-ASD surgery AAs undergoing RFA were included. Electrophysiological assessment included multipolar activation, entrainment and electroanatomic mapping. Clinical, ECG and Holter follow-up was conducted at 6 monthly intervals. Results: Mean age: 54 ± 13 years; 11 males. Time from surgical repair to RFA: 26 ± 16 years; LA size 4.4 ± 0.6 cm; 21/26 had a normal LVEF. The clinical arrhythmias were: CTI-dependent AFL (21), non-CTI-dependent AFL (14), dual-loop (14), focal atrial tachycardia (4), AVNRT (3) and LA AFL (1). Acute success was obtained in 88%; 9 patients required >1 procedure. All 4 patients with recurrent AFL (2 CTI-dependent, 2 non-CTI-dependent) at 13 ± 8 months had successful repeat RFA. At 3.2 ± 1.7 years follow-up since the last procedure, 87% of patients with successful RFA for AFL remained free of their clinical arrhythmia. However, 50% of the original 26 patients had documented AF or AFL which occurred 2.0 ± 1.6 years after the last procedure. Two patients suffered stroke (8%) in the context of AF; one was fatal. Conclusions: RFA for post-ASD surgery AAs is effective. However, late AF and AFL are common and may present with stroke. This has important implications for clinical follow-up and long-term stroke prophylaxis. doi:10.1016/j.hlc.2010.06.919
doi:10.1016/j.hlc.2010.06.920 254 Obstructive Events in Sleep Apnoea Causes Acute Atrial Remodelling in Patients with Atrial Fibrillation H. Dimitri 1,∗ , M. Ng 2 , A. Brooks 1 , N. Shipp 1 , N. Antic 1 , A. Thornton 2 , R. Antic 2 , P. Sanders 1 1 University
of Adelaide and Cardiovascular Research Centre, Royal Adelaide Hospital, Australia 2 Sleep Unit, Department of Thoracic Medicine, Royal Adelaide Hospital, Australia Background: The acute effects of airway obstruction on atrial electrophysiology in AF pts with OSA is not known. Methods: 6 pts with OSA (4 M; age 63 ± 6; BMI 31 ± 2; AHI 53 ± 25 events/h) undergoing electrophysiological study had a single custom-designed 20 pole catheter (10 poles in CS; 10 poles at the lateral RA) introduced via the RIJV and left in situ overnight post-procedure. Atrial refractoriness at the proximal CS and conduction time along the CS and LRA were determined serially before, during and with recovery from episodes of clinical
obstruction (as determined by simultaneous polysomnography). Results: 20 obstructive episodes met the inclusion criteria. Mean O2 at the beginning (B) of the events was 95 ± 2.6%, nadir (N) 86 ± 4.1% and recovery (R) 95 ± 2.3%. ERP changes were dynamic but not different at the 3 time points (p = 0.07). CT across the CS was not different for S1, however, was significantly different for S2 (134 ± 30 ms(B) vs. 148 ± 26 ms(N) vs. 147 ± 40 ms(R); p = 0.01). Lateral CT significantly changed for S1 (119 ± 20 ms(B) vs. 126 ± 18 ms(N) vs. 123 ± 20 ms(R)) and S2 (177 ± 44 ms(B) vs. 207 ± 38 ms(N) vs. 207 ± 48 ms(R); p = 0.03) measures. Local conduction delay (CD = A1A2 − S1S2) was significantly different at the distal CS (63 ± 20 ms(B) vs. 70 ± 15 ms(N) vs. 74 ± 24 ms(R); p = 0.01) and lateral RA (78 ± 26 ms(B) vs. 97 ± 21 ms(N) vs. 92 ± 30 ms(R); p < 0.001). Conclusion: Acute obstruction during sleep apnoea results in significant atrial remodelling characterized by slowing of conduction during obstruction and incomplete recovery after the event. These changes may account in part for the development of AF in association with clinical OSA. doi:10.1016/j.hlc.2010.06.921 255 Obstructive Sleep Apnoea and its Implications for Atrial Remodelling in Atrial Fibrillation H. Dimitri 1,∗ , M. Ng 2 , P. Kuklik 1 , A. Brooks 1 , M. Stiles 1 , A. Thornton 2 , R. Antic 2 , P. Sanders 1 1 University
of Adelaide and Cardiovascular Research Centre, Royal Adelaide Hospital, Australia 2 Sleep Unit, Department of Thoracic Medicine, Royal Adelaide Hospital, Australia Background: OSA is increasingly recognized as a risk factor for AF; however, its contribution to the atrial substrate is not known. Methods and results: 40 pts undergoing ablation for paroxysmal AF and in sinus rhythm for 48 h (20 with moderate-severe OSA (AHI ≥ 15); 20 with no OSA (AHI < 15) by overnight polysomnography) were studied. Multipolar catheters were positioned at the lateral RA, coronary sinus (CS), crista and RA septum: ERP (high/low lateral RA, proximal and distal CS, septal), conduction time along the RA and CS, number/duration of fractionated signals (FS > 50 ms) along the crista, and sinus node function (CSNRT) were measured. CARTO maps of the LA/RA were created to determine voltage, conduction and distribution of FS. There was no differences in established risk factors for AF. Pts with OSA had the following compared to those without OSA: no difference in ERP(228 ± 54 ms vs 226 ± 82 ms; p = 0.9); prolonged conduction times (CS/lateral RA: 45 ± 10 ms/51 ± 10 ms vs 51 ± 7 ms/58 ± 10 ms; p = 0.02); greater number and longer duration of FS along the crista (No./dur in SR: 2 ± 2/44 ± 19 vs 5 ± 1/62 ± 11; p = 0.003/0.03); longer
Abstracts
S109
P-wave duration (138 ± 8 ms vs 120 ± 15 ms; p = 0.01) longer CSNRT (397 ± 114 ms vs 266 ± 73 ms; p = 0.02); lower atrial voltage (RA/LA: 1.5 ± 0.1 mV/1.6 ± 0.2 mV vs 2.4 ± 0.2 mV/2.4 ± 0.1 mV p < 0.001/0.001), slower atrial conduction velocity(RA/LA: 0.8 ± 0.1 ms/0.9 ± 0.1 ms vs 1.2 ± 0.1 ms/1.2 ± 0.1 ms; p < 0.001/0.001); and more widespread FS in both atria (RA/LA (%): 22 ± 10/25 ± 8 vs 13 ± 5/16 ± 7; p = 0.02/0.01) Conclusion: OSA is associated with significant atrial remodelling characterized by atrial enlargement, loss of myocardium, site-specific and widespread conduction abnormalities and impaired sinus node function. These features may in part explain the association between OSA and AF. doi:10.1016/j.hlc.2010.06.922 256 Periatrial Fat Volume is Predictive of Atrial Fibrillation Severity H. Abed 1,∗ , C. Wong 2 , A. Brooks 3 , P. Molaee 1,2,3 , A. Nelson 1,2,3 , B. Dundon 1,2,3 , D. Leong 1,2,3 , G. Wittert 1,2,3 , S. Worthley 1,2,3 , W. Abhayaratna 1,2,3 , P. Sanders 1,2,3 1 The
Royal Adelaide Hospital, Australia of Medicine, The University of Adelaide, Australia 3 Canberra Hospital, Australia 2 Discipline
Introduction: Obesity is implicated as a risk factor for atrial fibrillation (AF). Studies have focused on the etiological significance of the pericardial fat depot, as opposed to visceral fat, in other cardiovascular diseases. We evaluated the association between pericardial fat volume and AF severity. Methods: Patients undergoing AF ablation (n = 61, 23 paroxysmal, 19 persistent and 19 permanent) underwent magnetic resonance imaging (1.5 Tesla, Siemens Avanto). Pericardial fat volumes were quantified using a technique previously validated ex vivo in an ovine model. The association between pericardial fat volume and persistent or permanent AF was studied, adjusting for AF risk factors (age, sex, body mass index [BMI], hypertension, obstructive sleep apnea and left atrial area). Results: There was a dose response association between AF severity (paroxysmal to persistent to permanent) and pericardial fat volume (periatrial [p < 0.001], periventricular [p = 0.046] and total [p = 0.001]). This is shown in the graph below. Periatrial fat volume, but not periventricular or total, was associated with more prolonged AF in a multivariable-adjusted model (for every 10% increase in fat; odds ratio [OR] 1.6, 95% CI 1.4–1.8). Adjustment for BMI did not change the association between periatrial fat volume and permanent AF (OR 1.5, CI 1.3–1.7). Conclusion: Periatrial fat, but not periventricular or total pericardial, is independently associated with AF severity. Our findings suggest a possible proarrhythmic effect of local adipose tissue contiguous to the atria.
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
Conclusion: SubM-ICD implantation in young females is safe with long term system performance that is satisfactory. A clinically insignificant RV pacing threshold rise with decrease in lead impedance was noted.
253 Noncontact Mapping System and CFAE Ablation Add to PVI Get Better for Chronic as AF on the First Session
doi:10.1016/j.hlc.2010.06.918
D. Yuasa ∗ , S. Kaneko, M. Shinoda, H. Kamiya, R. Kubota, Y. Tatami, M. Hayashi, H. Kanayama
252
Toyota Kosei Hospital, Japan
Long-term Outcome Following Ablation of Atrial Arrhythmias Occurring Late After Atrial Septal Defect Repair. High Incidence of Late Atrial Fibrillation
Backgrounds: To modify the atrial fibrillation (AF) substrate, complex fractionated atrial electrogram (CFAE) ablation seems to be effective. But the endpoint of CFAE ablation is unclear because of difficulty of confirming the disappearance of CFAE by usual mapping. Although the benefit of noncontact mapping (NCM) system in chronic AF (CAF) ablation is not validated, the disappearance of CFAE could be effectively confirmed by using NCM system in CAF ablation. Objectives: We evaluated the efficacy of NCM system guided CFAE ablation for CAF patients. Methods: We compared the recurrence rate of AF after catheter ablation in CAF patients who underwent either NCM system guided PVI+CFAE ablation (Group 1), using Laplacian bipolar or pulmonary vein isolation (PVI) + left atrial linear ablation (Group 2). From April 2005 to December 2009, we performed CAF ablation for 33 patients; 18 patients in Group 1 (6 patients underwent both atrial CFAE ablation) and 15 patients in Group 2. There were no significant differences in clinical characteristics between the two groups. Results: Mean follow up period was 9.6 ± 6.2 (Group 1) months vs. 8.0 ± 7.1 (Group 2) months. 77.8% in Group 1 was not AF and 15.4% in Group 2 was not AF after ablation (P < 0.01). Conclusions: AF substrate modification by NCM system guided CFAE ablation got effected in CAF patients.
A. Teh 1,∗ , C. Medi 1 , P. Sparks 1 , P. Kistler 1,2 , G. Lee 1 , J. Morton 1 , J. Vohra 1 , K. Halloran 1 , J. Kalman 1 1 Royal 2 Baker
Melbourne Hospital, Australia IDI Heart and Diabetes Institute, Australia
Background: In patients with surgical atrial septal defect (ASD) repair, late atrial arrhythmias (AAs) including cavo-tricuspid isthmus (CTI)-dependent and non-CTI-dependent scar-related flutter (AFL) are common. Radiofrequency ablation (RFA) of these arrhythmias has a high acute success rate. We aimed to characterize the incidence of late recurrences and late atrial fibrillation (AF) in this population. Methods: 26 consecutive patients with post-ASD surgery AAs undergoing RFA were included. Electrophysiological assessment included multipolar activation, entrainment and electroanatomic mapping. Clinical, ECG and Holter follow-up was conducted at 6 monthly intervals. Results: Mean age: 54 ± 13 years; 11 males. Time from surgical repair to RFA: 26 ± 16 years; LA size 4.4 ± 0.6 cm; 21/26 had a normal LVEF. The clinical arrhythmias were: CTI-dependent AFL (21), non-CTI-dependent AFL (14), dual-loop (14), focal atrial tachycardia (4), AVNRT (3) and LA AFL (1). Acute success was obtained in 88%; 9 patients required >1 procedure. All 4 patients with recurrent AFL (2 CTI-dependent, 2 non-CTI-dependent) at 13 ± 8 months had successful repeat RFA. At 3.2 ± 1.7 years follow-up since the last procedure, 87% of patients with successful RFA for AFL remained free of their clinical arrhythmia. However, 50% of the original 26 patients had documented AF or AFL which occurred 2.0 ± 1.6 years after the last procedure. Two patients suffered stroke (8%) in the context of AF; one was fatal. Conclusions: RFA for post-ASD surgery AAs is effective. However, late AF and AFL are common and may present with stroke. This has important implications for clinical follow-up and long-term stroke prophylaxis. doi:10.1016/j.hlc.2010.06.919
doi:10.1016/j.hlc.2010.06.920 254 Obstructive Events in Sleep Apnoea Causes Acute Atrial Remodelling in Patients with Atrial Fibrillation H. Dimitri 1,∗ , M. Ng 2 , A. Brooks 1 , N. Shipp 1 , N. Antic 1 , A. Thornton 2 , R. Antic 2 , P. Sanders 1 1 University
of Adelaide and Cardiovascular Research Centre, Royal Adelaide Hospital, Australia 2 Sleep Unit, Department of Thoracic Medicine, Royal Adelaide Hospital, Australia Background: The acute effects of airway obstruction on atrial electrophysiology in AF pts with OSA is not known. Methods: 6 pts with OSA (4 M; age 63 ± 6; BMI 31 ± 2; AHI 53 ± 25 events/h) undergoing electrophysiological study had a single custom-designed 20 pole catheter (10 poles in CS; 10 poles at the lateral RA) introduced via the RIJV and left in situ overnight post-procedure. Atrial refractoriness at the proximal CS and conduction time along the CS and LRA were determined serially before, during and with recovery from episodes of clinical
obstruction (as determined by simultaneous polysomnography). Results: 20 obstructive episodes met the inclusion criteria. Mean O2 at the beginning (B) of the events was 95 ± 2.6%, nadir (N) 86 ± 4.1% and recovery (R) 95 ± 2.3%. ERP changes were dynamic but not different at the 3 time points (p = 0.07). CT across the CS was not different for S1, however, was significantly different for S2 (134 ± 30 ms(B) vs. 148 ± 26 ms(N) vs. 147 ± 40 ms(R); p = 0.01). Lateral CT significantly changed for S1 (119 ± 20 ms(B) vs. 126 ± 18 ms(N) vs. 123 ± 20 ms(R)) and S2 (177 ± 44 ms(B) vs. 207 ± 38 ms(N) vs. 207 ± 48 ms(R); p = 0.03) measures. Local conduction delay (CD = A1A2 − S1S2) was significantly different at the distal CS (63 ± 20 ms(B) vs. 70 ± 15 ms(N) vs. 74 ± 24 ms(R); p = 0.01) and lateral RA (78 ± 26 ms(B) vs. 97 ± 21 ms(N) vs. 92 ± 30 ms(R); p < 0.001). Conclusion: Acute obstruction during sleep apnoea results in significant atrial remodelling characterized by slowing of conduction during obstruction and incomplete recovery after the event. These changes may account in part for the development of AF in association with clinical OSA. doi:10.1016/j.hlc.2010.06.921 255 Obstructive Sleep Apnoea and its Implications for Atrial Remodelling in Atrial Fibrillation H. Dimitri 1,∗ , M. Ng 2 , P. Kuklik 1 , A. Brooks 1 , M. Stiles 1 , A. Thornton 2 , R. Antic 2 , P. Sanders 1 1 University
of Adelaide and Cardiovascular Research Centre, Royal Adelaide Hospital, Australia 2 Sleep Unit, Department of Thoracic Medicine, Royal Adelaide Hospital, Australia Background: OSA is increasingly recognized as a risk factor for AF; however, its contribution to the atrial substrate is not known. Methods and results: 40 pts undergoing ablation for paroxysmal AF and in sinus rhythm for 48 h (20 with moderate-severe OSA (AHI ≥ 15); 20 with no OSA (AHI < 15) by overnight polysomnography) were studied. Multipolar catheters were positioned at the lateral RA, coronary sinus (CS), crista and RA septum: ERP (high/low lateral RA, proximal and distal CS, septal), conduction time along the RA and CS, number/duration of fractionated signals (FS > 50 ms) along the crista, and sinus node function (CSNRT) were measured. CARTO maps of the LA/RA were created to determine voltage, conduction and distribution of FS. There was no differences in established risk factors for AF. Pts with OSA had the following compared to those without OSA: no difference in ERP(228 ± 54 ms vs 226 ± 82 ms; p = 0.9); prolonged conduction times (CS/lateral RA: 45 ± 10 ms/51 ± 10 ms vs 51 ± 7 ms/58 ± 10 ms; p = 0.02); greater number and longer duration of FS along the crista (No./dur in SR: 2 ± 2/44 ± 19 vs 5 ± 1/62 ± 11; p = 0.003/0.03); longer
Abstracts
S109
P-wave duration (138 ± 8 ms vs 120 ± 15 ms; p = 0.01) longer CSNRT (397 ± 114 ms vs 266 ± 73 ms; p = 0.02); lower atrial voltage (RA/LA: 1.5 ± 0.1 mV/1.6 ± 0.2 mV vs 2.4 ± 0.2 mV/2.4 ± 0.1 mV p < 0.001/0.001), slower atrial conduction velocity(RA/LA: 0.8 ± 0.1 ms/0.9 ± 0.1 ms vs 1.2 ± 0.1 ms/1.2 ± 0.1 ms; p < 0.001/0.001); and more widespread FS in both atria (RA/LA (%): 22 ± 10/25 ± 8 vs 13 ± 5/16 ± 7; p = 0.02/0.01) Conclusion: OSA is associated with significant atrial remodelling characterized by atrial enlargement, loss of myocardium, site-specific and widespread conduction abnormalities and impaired sinus node function. These features may in part explain the association between OSA and AF. doi:10.1016/j.hlc.2010.06.922 256 Periatrial Fat Volume is Predictive of Atrial Fibrillation Severity H. Abed 1,∗ , C. Wong 2 , A. Brooks 3 , P. Molaee 1,2,3 , A. Nelson 1,2,3 , B. Dundon 1,2,3 , D. Leong 1,2,3 , G. Wittert 1,2,3 , S. Worthley 1,2,3 , W. Abhayaratna 1,2,3 , P. Sanders 1,2,3 1 The
Royal Adelaide Hospital, Australia of Medicine, The University of Adelaide, Australia 3 Canberra Hospital, Australia 2 Discipline
Introduction: Obesity is implicated as a risk factor for atrial fibrillation (AF). Studies have focused on the etiological significance of the pericardial fat depot, as opposed to visceral fat, in other cardiovascular diseases. We evaluated the association between pericardial fat volume and AF severity. Methods: Patients undergoing AF ablation (n = 61, 23 paroxysmal, 19 persistent and 19 permanent) underwent magnetic resonance imaging (1.5 Tesla, Siemens Avanto). Pericardial fat volumes were quantified using a technique previously validated ex vivo in an ovine model. The association between pericardial fat volume and persistent or permanent AF was studied, adjusting for AF risk factors (age, sex, body mass index [BMI], hypertension, obstructive sleep apnea and left atrial area). Results: There was a dose response association between AF severity (paroxysmal to persistent to permanent) and pericardial fat volume (periatrial [p < 0.001], periventricular [p = 0.046] and total [p = 0.001]). This is shown in the graph below. Periatrial fat volume, but not periventricular or total, was associated with more prolonged AF in a multivariable-adjusted model (for every 10% increase in fat; odds ratio [OR] 1.6, 95% CI 1.4–1.8). Adjustment for BMI did not change the association between periatrial fat volume and permanent AF (OR 1.5, CI 1.3–1.7). Conclusion: Periatrial fat, but not periventricular or total pericardial, is independently associated with AF severity. Our findings suggest a possible proarrhythmic effect of local adipose tissue contiguous to the atria.
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268