Tuesday, September 16, 2008

Patient Perspective :Left atrial image registration to guide catheter ablation of atrial fibrillation: In the eye of the technology

Citation : Osmar Antonio Centurion.Left atrial image registration to guide catheter ablation of atrial fibrillation: In the eye of the technology .JAFIB.2008 Sep;1(3): 190-193.


Your EP doctor uses state-of-the-art imaging techniques to evaluate and treat Atrial Fibrillation. The currently used imaging methods include Transthoracic echocardiography, Transesophageal echocardiography (or TEE), Intracardiac echocardiography (ICE), Magnetic resonance angiography, MRI and multidetector CT.

Using these techniques it would be feasible to identify any clots (thormbi) before any procedure. Before any ablation procedure it is important to understand the anatomy of the left atrium and pulmonary vein.

In this editorial comment Dr. Osmar Centurion from Division of Electrophysiology and Arrhythmia Cardiovascular Institute in Asuncion, Paraguay provides an overview of relevance of technology in use of imaging for Afib management.

Left atrial image registration to guide catheter ablation of atrial fibrillation: In the eye of the technology

Atrial fibrillation is a common arrhythmia, and its incidence rise sharply with age and with heart failure. Since the beginning of the new millennium, the debate on ectopic foci versus reentry as the mechanism underlying atrial fibrillation (AF) in humans has continuously evolved. The finding of ectopic beats proceeding from the pulmonary veins in the initiation of atrial fibrillation gave a different approach to the therapeutic management of this arrhythmia. Recently, the mechanism of AF is considered to be a spiral wave with a continuously changing pattern of the activation wavefront, that is, a random multiple reentry of independent wavelets wandering in the atria around arcs of refractory tissue or the accentuation of focal activity originating mainly from the pulmonary veins, the superior or inferior vena cava, the ligament of Marshall, or even the right atrium.

Patient Perspective : Physical Activity and Incidence of Atrial Fibrillation in Older Adults: The Cardiovascular Health Study

Suneet Mittal. Physical Activity and Incidence of Atrial Fibrillation in Older Adults: The Cardiovascular Health Study .JAFIB.2008 Sep;1(3): 185-186.


Dr. Mittal from The St. Luke's-Roosevelt Hospital Center,Columbia University College of Physicians & Surgeons,New York, NY reviews the recently published study showing the benefits of light to moderate exercise in significantly lowering AF incidence in older adults.

Physical Activity and Incidence of Atrial Fibrillation in Older Adults: The Cardiovascular Health Study

Retrospective case-control studies and case series of younger athletes and middle-aged adults have suggested an adverse association between physical activity and development of atrial fibrillation. However, these studies have evaluated subjects engaged in either vigorous exertion or endurance training. On the other hand, habitual physical activity might be expected through salutatory effects on blood pressure, vascular compliance, coronary disease, and heart failure to reduce the incidence of atrial fibrillation in the general population. The aim of this study was to assess the effect of habitual light to moderate physical activity on the incidence of atrial fibrillation among older adults.

Patient Perspective :Underutilization of Warfarin Therapy in Elderly Patients with Atrial Fibrillation – Fear or False Sense of Security!

Citation :Mazda Biria, Ahmad Batrash, James Vacek, Loren Berenbom, Dhanunjaya Lakkireddy.Underutilization of Warfarin Therapy in Elderly Patients with Atrial Fibrillation – Fear or False Sense of Security! .JAFIB.2008 Sep;1(3): 133-138.


Warfarin (also known under the brand names Coumadin, Jantoven, Marevan, and Waran) is an anticoagulant. It is named after the Wisconsin Alumni Research Foundation, which sponsored its development. Patients with Atrial Fibrillation (AF) have an increased risk of clots (or thrombi) due to irregular heart beat.

Dr. Batrash et al from Kansas City Veterans Affairs Medical Center, Kansas City report a retrospective study showing underutilization of warfarin in elderly patients with AF due to false sense of security about the paroxysmal nature of AF, lack of proper insight about stroke risk (CHADS (2)), and fear of bleeding.

Underutilization of Warfarin Therapy in Elderly Patients with Atrial Fibrillation – Fear or False Sense of Security!

Background: Under utilization of warfarin in elderly patients with atrial fibrillation (AF) has been recognized as a significant health care issue. This study examines the rate and reasons for warfarin underutilization in elderly patients with AF at the Kansas City Veterans Affairs Medical Center.

Methods: Retrospective study reviewing electronic medical records of all patients aged 65 and older with the diagnosis of atrial fibrillation. Patients on warfarin were excluded. Reasons for not using warfarin were extracted by reviewing the electronic medical record. Anticoagulation indications for these patients were determined based on the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation.

Results:Warfarin was not used by 407 patients (25%) with known AF. Average age was 79+6.2 years. 60% of patients had persistent or permanent AF. Prevalence of risk factors for thromboembolism included hypertension (74%), heart failure or ejection fraction of <40%

Conclusions:Underutilization of warfarin in elderly patients with atrial fibrillation remains a common problem despite their high risk for thromboembolic events. A false sense of security about the paroxysmal nature of AF, lack of proper insight about stroke risk (CHADS (2)), and fear of bleeding are the most common reasons for non use of warfarin.

Patient Perspective :Echocardiographic Prediction of Symptomatic Atrial Fibrillation In Patients with Rheumatic Mitral Stenosis and Normal Sinus Rhyth

Citation : Fahriye Vatansever Agca, Ozan Kinay, Mustafa Karaca,Muge Ildizli Demirbas,Serdar Biceroglu,Baris Kilicarslan,Cem Nazli,A. Oktay Ergene.Echocardiographic Prediction of Symptomatic Atrial Fibrillation In Patients with Rheumatic Mitral Stenosis and Normal Sinus Rhythm. JAFIB .2008 Sep;1(3): 139-144.


Mitral stenosis is a valvular heart disease characterized by the narrowing of the orifice of the mitral valve of the heart.Rheumatic mitral stenosis (RMS) increases the risk of both atrial fibrillation (AF) and thromboembolism.

Dr. Karaca et al from Atakalp Heart Hospital Cardiology Department,Turkey report the benefit of echocardiography to predict symptomatic AF in a study on patients with mitral stenosis and normal sinus rhythm.


Echocardiographic Prediction of Symptomatic Atrial Fibrillation In Patients with Rheumatic Mitral Stenosis and Normal Sinus Rhythm

Objectives: Rheumatic mitral stenosis (RMS) increases the risk of both atrial fibrillation (AF) and thromboembolism. 
Methods: Patients with mitral stenosis and normal sinus rhythm were enrolled in the study prospectively.The present study was designed to study whether echocardiographic evaluation in patients with mitral stenosis and normal sinus rhythm could predict the occurrence of symptomatic AF . 
Results: Sixty-two patients (51 females) with mitral stenosis and normal sinus rhythm were included in the study. Seven patients (11.2%) developed symptomatic AF and the remaining 55 were free of AF during a followed-up of 22±5 months. The following echocardiographic parameters were significantly increased and predicted the development of AF: left atrial(LA) mediolateral diameter (5.5 ± 0.5 cm vs 4.7 ± 0.7 cm), right atrial mediolateral diameter (4,7 ± 1.0 cm vs 3.6 ± 1.3 cm), LA area in the apical two chamber view ( 31 ± 3.2 cm2 vs 25 ± 5.8 cm2), right atrial volume (52 ± 22 cm3 vs 34 ± 19 cm3), and interatrial conduction time (IACT) (132 ± 22 msec vs 115 ± 16 msec). 
Conclusions: This study revealed that echocardiography can be used to predict symptomatic AF in patients with RMS and sinus rhythm.

Patient Perspective : Atrial Septal Defect and Atrial Fibrillation

Citation : George E. Blake, Dhanunjaya Lakkireddy. Atrial Septal Defect and Atrial Fibrillation. JAFIB .2008 Sep;1(3):173-184.


Atrial septal defect (ASD) is a form of congenital heart defect that enables blood flow between the left and right atria via the interatrial septum. The interatrial septum is the tissue that divides the right and left atria. Without this septum, or if there is a defect in this septum, it is possible for blood to travel from the left side of the heart to the right side of the heart, or vice versa.

Atrial Fibrillation (AF) is a common complication of ASD, and Dr. Blake et al from University of Kansas, Kansas City, KS discuss the diagnosis and management of ASD and AF.

Atrial Septal Defect and Atrial Fibrillation

Atrial fibrillation (AF) is a common complication in patients with atrial septal defects (ASDs). The link between AF and ASD is fairly complex and entails modifications in electrophysiologic, contractile and structural properties, at the cellular and tissue level, of both atria, mainly due to chronic atrial stretch and dilation. Surgical repair or transcatheter closure of ASDs are equally effective in reducing mortality and symptoms but limited in preventing or curbing AF, unless combined with an arrhythmia-specific procedure. Transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) have improved the safety and success of the above procedures. Finally, clearer understanding of the pathophysiology of AF in patients with ASD (and CHF, in general) has led to target-specific advances in medical management.

Patient Perspective :Impact of Smoking on the Atrial Substrate Characteristics in Patients with Atrial Fibrillation

Citation : Ta-Chuan Tuan,Shih-Lin Chang, Shih-Ann Chen.Impact of Smoking on the Atrial Substrate Characteristics in Patients with Atrial Fibrillation .JAFIB.2008 Sep;1(3): 170-172.

Smoking has multiple adverse effects on health and is known to be linked to Atrial fibrillation. In a brief review Dr. Steven-Chen et al from Taipei Veterans General Hospital discuss the effects of smoking on the causation, progression and management of Atrial fibrillation.

Impact of Smoking on the Atrial Substrate Characteristics in Patients with Atrial Fibrillation

Cigarette smoking is a common health issue throughout the world. It can cause the development of various major diseases, such as chronic obstructive pulmonary disease (COPD), most cardiovascular diseases and many types of cancer. Thus, people with a tobacco habit can produce devastating health consequences for themselves. At present, there are about five million people that die annually, which can be attributed to cigarette smoking, and half of those deaths, which are mortalities from smoking, always occur in middle age. Therefore, how to reduce cigarette smoking remains the most important work to avoid the causes of health disabilities and premature death.

Patient Perspective :Sinus Node Dysfunction in Atrial Fibrillation: Cause or Effect?

Citation : Anna Kezerashvili,Andrew K. Krumerman, John D. Fisher. Sinus Node Dysfunction in Atrial Fibrillation: Cause or Effect? .JAFIB.2008 Sep;1(3): 161-169.

Sick sinus syndrome, also called Sinus node dysfunction (SSS), is a group of abnormal heart rhythms (arrhythmias) presumably caused by a malfunction of the sinus node, the heart's "natural" pacemaker. Bradycardia-tachycardia syndrome is a variant of sick sinus syndrome where atrial flutter and fibrillation alternate with prolonged periods of asystole.

SSS often coexists with Atrial Fibrillation, and in this extensive and interesting review Dr. Fisher et al., from Montefiore Medical Center and Albert Einstein College of Medicine explore the close interplay between the two conditions.

Sinus Node Dysfunction in Atrial Fibrillation: Cause or Effect?

Atrial fibrillation (AF) and sick sinus syndrome (SSS) are two conditions that frequently coexist. Despite a wealth of available knowledge, the link between these two entities is poorly understood. Whether AF is a harbinger of SSS or whether SSS predisposes to AF has been the subject of much debate. AF results in sinus node remodeling on a cellular and molecular basis that may promote SSS. However, not all patients with atrial fibrillation have SSS. Though “AF begets AF”, AF may also beget SSS; and SSS may also beget AF. Multiple studies have demonstrated that sinus node dysfunction may precede the onset of AF. This review will focus on alterations to sinus node structure and function, overdrive suppression, ion channel remodeling, and transient myocardial ischemia as possible mechanisms associated with AF induced SSS. In addition, we will review evidence suggesting that SSS, characterized by a combination of atrial extrasystoles, dispersion of excitability recovery and sinus node ischemia, may lead to AF. Additional factors common to both conditions such as aging and interstitial atrial fibrosis, may explain their coexistence. All this raises many therapeutic challenges associated with the interplay of AF and SSS.

Patient Perspective : GIANT Flutter Waves in ECG Lead V1: a Marker of Pulmonary Hypertension

Citation : James A. Reiffel. GIANT Flutter Waves in ECG Lead V1: a Marker of Pulmonary Hypertension .JAFIB.2008 Sep;1(3): 187-189.

Atrial Flutter is a common heart rhythm abnormality that may or may not be associated with problems cardiac anatomy. The current diagnosis methods with ECG do not offer direct information on the anatomical defect.

In the case report Dr. Reiffel from Section of Electrophysiology, Columbia University College of Physicians and Surgeons and The New York Presbyterian Hospital, NY reports the novel ECG pattern that may allow detection of patients with pulmonary hypertension and Atrial flutter.

Cardiac Image Registration

Long procedure time and somewhat suboptimal results hinder the widespread use of catheter ablation of complex arrhythmias such as atrial fibrillation (AF). Due to lack of contrast differentiation between the area of interest and surrounding structures in a moving organ like heart, there is a lack of proper intraprocedural guidance using current imaging techniques for ablation. Cardiac image registration is currently under investigation and is in clinical use for AF ablation. Cardiac image registration, which involves integration of two images in the context of left atrium (LA), is intermodal, with the acquired image and the real-time reference image residing in different image spaces, and involves optimization, where one image space is transformed into the other. Unlike rigid body registration, cardiac image registration is unique and challenging due to cardiac motion during the cardiac cycle and due to respiration. This review addresses the basic principles of the emerging technique of registration and the inherent limitations as they relate to cardiac imaging and registration.

GIANT Flutter Waves in ECG Lead V1: a Marker of Pulmonary Hypertension

Atrial flutter (AFl) may exist with or without underlying structural heart disease. Typical AFl presents as a “sawtooth” pattern on the ECG – with inverted flutter (F) waves in the inferior leads and upright F waves in V1. This morphology offers no direct clues as to the underlying cardiac disorder, if any. Occasionally we have encountered giant F waves, most prominently in lead V1, reaching 5 mv or more in height – sometimes exceeding the QRS voltage. The significance of this pattern has not been investigated and reported on. To determine if giant F waves in V1 provide any insight into the presence/type/absence of specific underlying cardiac pathology, the history of 6 consecutive patients with giant F waves was reviewed. Upon review, the only factor common to each patient was the presence of or history of pulmonary hypertension. Right ventricular dilation and/or dysfunction and right atrial enlargement with or without tricuspid insufficiency were present in each by echocardiography. Giant F waves appear to occur in the setting of right heart dysfunction in patients with a history of or the continued presence of pulmonary hypertension. Their detection should indicate the need for right heart evaluation.

Patient Perspective : Cardiac Image Registration

Citation : Jasbir Sra.Cardiac Image Registration .JAFIB.2008 Sep;1 (3): 145-160.

Your EP doctor uses state-of-the-art imaging techniques to evaluate and treat Atrial Fibrillation. The currently used imaging methods include Transthoracic echocardiography, Transesophageal echocardiography (or TEE), Intracardiac echocardiography (ICE), Magnetic resonance angiography, MRI and multidetector CT. 


Using these techniques it would be feasible to identify any clots (thormbi) before any procedure. Before any ablation procedure it is important to understand the anatomy of the left atrium and pulmonary vein. 

In this extensive review Dr. Jasbir Sra from Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health- Milwaukee Clinical Campus, Wisconsin discusses the advances in technology for use of imaging methods and comprehensive report on different clinical studies which have used imaging methods in patients with Atrial Fibrillation.