Saturday, October 31, 2009

Role of Inflammation in Early AF Recurrence after PV Isolation

Citation : Rupa Bala.Role Of Inflammation In Early AF Recurrence After PV Isolation .JAFIB.2009 October;Volume 1 Issue(9): 555-558.

Recently, there has been a great deal of interest in the mechanistic role of inflammation in the initiation, maintenance, and perpetuation of atrial fibrillation (AF). Several studies have focused on inflammatory biomarkers and acute-phase proteins to further understand the inflammatory milieu in relation to AF. These studies have demonstrated that both interleukin-6 (IL-6) and C-reactive protein (CRP) are elevated in paroxysmal and persistent AF. Chung et al. demonstrated an association between elevated CRP levels and AF in a nonoperative setting. In this study, CRP levels were more than 2-fold higher in patients with AF than in control subjects. Moreover, patients with persistent AF had higher CRP levels than patients with paroxysmal AF, suggesting that inflammation may be more relevant to promoting AF maintenance than its initiation.

The Role of Intracardiac Echocardiography in Atrial Fibrillation Ablation

Citation : Elad Anter, Mathew D. Hutchinson, David J. Callans.The Role of Intracardiac Echocardiography in Atrial Fibrillation Ablation .JAFIB.2009 October;Volume 1 Issue(9): 545-554.

Radiofrequency catheter ablation of pulmonary veins has emerged as an effective therapy for patients with symptomatic atrial fibrillation. Advances in real-time intracardiac echocardiography with 2D and Doppler color flow imaging have led to its integration in atrial fibrillation ablation procedures. It allows imaging of the left atrium and pulmonary veins, including identification of anatomic variations. It has an important role in guiding transseptal catheterization, imaging the pulmonary vein ostia, assisting in accurate placement of mapping and ablation catheters, monitoring lesion morphology and flow changes in the ablated pulmonary veins, hence allowing titration of energy delivery. Importantly, it allows instant detection of procedural complications.

Atrial Fibrillation in Hypertrophic Obstructive Cardiomyopathy - Antiarrhythmics, ablation and more!

Citation : Gangadhar Malasana, John D. Day, T. Jared Bunch.Atrial Fibrillation in Hypertrophic Obstructive Cardiomyopathy - Antiarrhythmics, ablation and more! .JAFIB.2009 October;Volume 1 Issue(9): 535-544.

Hypertrophic cardiomyopathy (HCM) is a genetic disease of the cardiac sarcomere with an autosomal dominant pattern of inheritance. Patients with HCM are at high risk of developing atrial fibrillation (AF) particularly in the setting of advanced diastolic dysfunction and left atrial enlargement. AF is a marker of increased mortality and morbidity and results in a significant reduction in quality of life. Antiarrhythmic medications improve symptoms and reduce AF recurrence, but few are safe and there exists little data to guide their long-term use in HCM. Non-pharmacologic approaches have emerged and have equal or greater efficacy than pharmacologic approaches. Although these approaches are promising, the long-term impact on atrial function needs to be carefully studied as it may impact quality of life in patients that age in the setting of a progressive diastolic disease disorder. Nonetheless, with the significant impact of AF in HCM, rhythm control strategies are often required. The understanding of rhythm control strategies in HCM, an often rapidly progressive diastolic dysfunction disorder, may provide insight in how to treat the much more prevalent AF patient with hypertensive cardiomyopathy. Regardless of treatment strategy (rhythm or rate control) patients are a moderate to high risk of thromboembolism and until data are available to suggest otherwise require long-term warfarin anticoagulation.

Review of Dominant Frequency Analysis in Atrial Fibrillation

Citation : Rakesh Latchamsetty, Abraham G Kocheril.Review of Dominant Frequency Analysis in Atrial Fibrillation .JAFIB.2009 October;Volume 1 Issue(9): 531-534.

Significant advancements have been made in the technology and approach to catheter ablation of atrial fibrillation (AF). Pulmonary vein isolation has emerged as the predominate strategy in this procedure and has fueled innovations in catheter design as well as various mapping and navigation systems. Mapping and targeting of complex fractionated atrial electrograms has also emerged as an additional or alternate strategy employed by some ablationists. Recently, attention is being drawn to a new approach targeting atrial sites with high dominant frequencies (DF) derived from their electrograms. This article is a review of the basic concepts of DF, some of the literature on which these were based, and the potential clinical applicability of DF analysis for ablation of AF.

Pulmonary Vein Isolation using a High Density Mesh Ablator Catheter: incorporation of three-dimensional navigation and mapping

Citation :Dr Jiun Tuan, Dr Mohamed Jeilan, Dr Faizel Osman, Dr Suman Kundu, Dr Rajkumar Mantravadi, Dr Peter J Stafford, Dr G Andre Ng.Pulmonary Vein Isolation using a High Density Mesh Ablator Catheter: incorporation of three-dimensional navigation and mapping .JAFIB.2009 October;Volume 1 Issue(9): 510-518.

Background We evaluated the use of a novel High Density Mesh Ablator (HDMA) catheter in combination with three-dimensional navigation for the treatment of paroxysmal atrial fibrillation.
Methods The HDMA catheter was used to carry out pulmonary vein isolation in a consecutive series of patients. Three-dimensional geometry of the left atrial-pulmonary vein (LA-PV) junctions were first created with the HDMA catheter. Ostial, proximal and distal sites within the pulmonary veins were tagged with catheter shadows on the created geometry to allow for re-interrogation of these exact sites after ablation.
Results The HDMA catheter was successfully used to create three dimensional geometry of the LA-PV junction in a total of 20 pulmonary veins which involved 5 patients. In all cases, ostial ablation alone was sufficient to achieve electrical isolation. No significant pulmonary vein stenosis was seen acutely after ablation.
Conclusion We describe the successful use of the novel HDMA catheter to create three-dimensional geometry of the LA-PV junction to assist with pulmonary vein isolation.

Percutaneous Left Atrial Appendage Occlusion Therapy: Who, Why and How?

Citation : Sven Mobius-Winkler, Ingo Dahnert, Gerhard C. Schuler and Peter B. Sick.Percutaneous Left Atrial Appendage Exclusion Therapy: Who, Why and How? .JAFIB.2009 October;Volume 1 Issue(9): 519-530.

The diagnosis of atrial fibrillation (AF) significantly increases the risk of having cardio embolic events. Cerebrovascular events are still a leading cause of death and disability worldwide. Current guidelines recommend an antithrombotic regimen to prevent thromboembolism in medium and high risk patients with AF. However, a substantial number of patients are not eligible for this therapy. Therefore, an exclusion of the left atrial appendage (LAA) from circulation seems to be an alternative strategy for stroke prevention in AF. This review focuses on the different strategies for LAA exclusion with a special focus on the WATCHMAN®-device.

Two devices are currently in use for percutaneous transcatheter occlusion of the LAA: the WATCHMAN®-device and the AMPLATZER®–Cardiac plug. Only for the WATCHMAN®-device safety, feasibility and non inferiority data compared to standard therapy data are currently available.

Additionally, about 200 patients at high risk for thromboembolic stroke and contraindications for oral anticoagulation therapy received the PLAATO® –device which is currently off the market.

The WATCHMAN®-device was implanted in 800 patients that were eligible for long-term anticoagulation therapy with a moderate risk for thromboembolic stroke due to non-valvular AF.

Current evidence indicates an equivalent risk of stroke compared to oral anticoagulation with a reduced rate of bleeding complications at least for the WATCHMAN®-device. Hence, another therapeutic option now is available to prevent thrombembolic events in patients with atrial fibrillation not suitable for medical anticoagulation therapy.

Key Words : atrial fibrillation, stroke, left atrial appendage, WATCHMAN® - device, Amplatzer® septal occluder, Amplatzer® cardiac plug

Thursday, August 20, 2009

Epicardially Based Pulmonary Vein Isolation for the Treatment of Atrial Fibrillation Utilizing Laser Energy in the Pig Model

Citation : Li Poa, M.D, Jane Olin, DVM, Lester Wong, M.D, Philip Poa, CP, Pablo Zubiate, M.D, C.C.P, Christina Poa, CP.Epicardially Based Pulmonary Vein Isolation for the Treatment of Atrial Fibrillation Utilizing Laser Energy in the Pig Model.JAFIB.2009 August;Volume 1 Issue(8): 505-509.

Purpose - Atrial fibrillation is a common disease that increases the incidence of cerebrovascular embolic events and cardiac dysfunction. Foci for atrial fibrillation have been mapped and found to be for the most part located within the ostia of the pulmonary veins. Since 2002 microwave and radiofrequency energy sources have been used to create pulmonary vein isolation lesions. This abstract summarizes the safety and efficacy of performing vein isolation lesions with laser as the energy source.
Description - The large pig model was utilized for creation of isolation lesions around the pulmonary veins. The Optimaze E360 Surgical Ablation Handpiece from Edwards Lifesciences was utilized, it contains a 4 centimeter diffusing diode laser (980nm). All six of the pig models tolerated the procedure with a 40-day normal post procedure growth pattern.
Evaluation - Upon reoperation one pig developed ventricular fibrillation with resection of adhesions. All five remaining pigs were fully tested and demonstrated complete electrical isolation. Gross pathology revealed intact well defined ablation lesions with an otherwise completely normal cardiac structure. All lesions were fully transmural at each histological sectioned point.
Conclusions - Laser technology in the form of the Optimaze E360 Surgical Ablation Handpiece from Edwards Lifesciences, is able to reliably and consistently produce well defined electrical isolation scars around the pulmonary veins. This device is also amenable to performing the isolation procedure using a minimally invasive approach.

Key Words: atrial fibrillation, pulmonary vein, laser

Dronedarone For Atrial Fibrillation: Unbridled Enthusiasm Or Just Another Small Step Forward?

Citation : James A. Reiffel, M.D.Dronedarone For Atrial Fibrillation: Unbridled Enthusiasm Or Just Another Small Step Forward? .JAFIB.2009 August;Volume 1 Issue(8): 500-504.

The Federal Food and Drug Administration (FDA) approved the marketing of dronedarone (Multaq, sanofi-aventis) for use in patients with atrial fibrillation (AF) or flutter (AFL) [with a requirement for a recent episode] that is paroxysmal or persistent – the latter having been converted to sinus rhythm or with conversion planned – who have, in addition to AF, certain “high-risk” markers for adverse outcomes that were derived from the enrollment criteria for the landmark ATHENA trial (1). These markers include one or more of: age >70 yrs, hypertension, diabetes mellitus, prior cerebrovascular accident, left atrial size of 50 mm or larger, or LVEF <40%. Contraindications include class IV heart failure or symptomatic heart failure with a recent decompensation; second or third degree AV block without a functioning pacemaker; bradycardia < 50 bpm; concomitant use of a strong CYP3A inhibitor or a QT prolonging agent that may induce torsades de pointes; QTc Bazett interval of 500 ms or longer; or severe hepatic impairment.

Paroxysmal Lone Atrial Fibrillation is Associated with an Abnormal Atrial Substrate: Characterizing the “Second Factor”

Citation : Charles R. Mitchell, MD and Mithilesh K. Das, MD.Paroxysmal Lone Atrial Fibrillation Is Associated With An Abnormal Atrial Substrate: Characterizing The “Second Factor” .JAFIB.2009 August;Volume 1 Issue(8): 496-499.

Stiles et al, recently published a study titled “Paroxysmal Lone Atrial fibrillation is associated with an abnormal atrial substrate: Characterizing the Second Factor” in The Journal of The American College of Cardiology.” Authors demonstrated structural and electrophysiological abnormalities in the atria of patients with paroxysmal lone atrial fibrillation (AF). The authors postulate that these factors are likely contributors to the “second factor” that predisposes to the development and progression of AF.

Atrial Fibrillation Ablation: First-Line Therapy?

Citation : Atul Verma MD.Atrial Fibrillation Ablation: First-Line Therapy? .JAFIB.2009 August;Volume 1 Issue(8): 487-495.

Background: Ablation for atrial fibrillation (AF) is a widely-accepted treatment for this arrhythmia. Ablation is traditionally reserved for second-line therapy in patients who have failed drug therapy, but it may be ready for first-line treatment.
Objective: This article outlines the rationale for using ablation as first-line therapy for AF.
Findings: AF increases both morbidity and mortality. Unfortunately, drug-based therapy for AF is very ineffective and may contribute adversely to both patient morbidity and mortality. Ablation addresses the root causes of AF and thus may be curative. The technique for ablation has become quite consistent and the outcomes better than those with drug therapy. The complication risk is also acceptably low. There is even preliminary evidence to suggest that AF ablation is superior as first-line treatment compared to drugs.
Conclusion: AF ablation is rapidly evolving towards becoming first-line therapy for some patients with this debilitating arrhythmia.

The Autonomic Nervous System and Atrial Fibrillation: The Roles of Pulmonary Vein Isolation and Ganglionated Plexi Ablation

Citation : Benjamin J. Scherlag, PhD, Hiroshi Nakagawa, M.D, Ph.D, Eugene Patterson, PhD, Warren M. Jackman, MD, Ralph Lazzara, MD, Sunny S. Po, MD, PhD.The Autonomic Nervous System and Atrial Fibrillation: The Roles of Pulmonary Vein Isolation and Ganglionated Plexi Ablation .JAFIB.2009 August;Volume 1 Issue(8): 471-486.

After the sequential successes of catheter ablation for the treatment of preexcitation syndromes (WPW), junctional reentry (AVNRT) atrial flutter (AFL) and ventricular arrhythmias, clinical electrophysiologists have focused on the myocardial basis of atrial fibrillation (AF). Thus, the strategy for ablation of drug and cardioversion refractory AF was to isolate the myocardial connections from the focal firing pulmonary veins (PVs) in addition to altering the atrial substrate maintaining AF. However, the overall success rates have not achieved the success rates of the other types of ablation procedures. In this review we have summarized the favorable aspects and drawbacks of pulmonary vein isolation (PVI). As for the role of the Intrinsic Cardiac Autonomic Nervous System (ICANS), both basic and clinical evidence has shown that ganglionated plexi (GP) stimulation promotes initiation and maintenance of AF, and that GP ablation reduces recurrence of AF following catheter or surgical ablation of these structures. Based on these findings, the GP Hyperactivity Hypothesis has been proposed to explain, at least in part, the mechanistic basis for the focal form of AF. For example, PV isolation may not always be necessary for elimination of AF, as in paroxysmal AF. GP ablation alone, in these cases, may suffice for focal AF termination. In the persistent and chronic forms the substrate for AF may be more extensive and therefore require GP ablation plus PV isolation and/or CFAE ablations. Clinical reports, both catheter based as well as minimally invasive surgical procedures, which include PVI plus GP ablation have shown relatively long-term success rates much closer to or equal to those achieved by myocardial ablation procedures in patients with WPW, AVNRT and AFL.

Cost-effectiveness of Catheter Ablation Treatment for Patients with Symptomatic Atrial Fibrillation

Citation :Nathalie Eckard , Thomas Davidson1 , Hakan Walfridsson , Lars-Ake Levin.Cost-effectiveness of Catheter Ablation Treatment for Patients with Symptomatic Atrial Fibrillation .JAFIB.2009 August;Volume 1 Issue(8): 461-470.

Background: Atrial Fibrillation is the most common cardiac arrhythmia. It increases the risk of thromboembolic events and many atrial fibrillation patients suffer quality of life impairment due to disturbed heart rhythm. Pulmonary vein isolation using radiofrequency catheter ablation treatment is aimed at maintaining sinus rhythm ultimately improving quality of life. Randomized clinical trial have shown that catheter ablation is more effective than antiarrhythmic drugs for the treatment of atrial fibrillation, but its impact on quality of life and cost-effectiveness has not been widely studied.
Aims: To assess the cost-effectiveness of radiofrequency ablation (RFA) vs. antiarrhythmic drug (AAD) treatment, among symptomatic atrial fibrillation patients not previously responding to AAD.
Methods: A decision-analytic Markov model was developed to assess costs and health outcomes in terms of quality adjusted life years (QALYs) of RFA and AAD over a lifetime time horizon. We conducted a literature search and used data from several sources as input variables of the model. One-year rates of atrial fibrillation with RFA and AAD, respectively, were available from published randomized clinical trials. Other data sources were published papers and register data.
Results: The RFA treatment strategy was associated with reduced costs and an incremental gain in QALYs compared to the AAD treatment strategy. The results were sensitive to whether long-term quality of life improvement is maintained for the RFA treatment strategy and the risk of stroke in the different atrial fibrillation health states.
Conclusion: This study shows that the short-term improvement in atrial fibrillation associated with RFA is likely to lead to long-term quality of life improvement and lower costs indicating that RFA is cost-effective compared to AAD.

Laser Ablation Of Atrial Fibrillation: Mid-Term Clinical Experience

Citation : Li Poa, MD, Miguel Puig, MD, Pablo Zubiate, MD, Edward Ranzenbach, PAC, Shari-Knutson Miller, PAC, Christina Poa, PC.Laser Ablation Of Atrial Fibrillation: Mid-Term Clinical Experience .JAFIB.2009 August;Volume 1 Issue(8): 454-460.

Background: Atrial Fibrillation is known to account for one third of all the strokes caused in the US in the population above the age of 70. Patients treated with the surgical Cox MAZE operation have been shown to have a 150 fold decrease in the incidence of stroke over an 18 year period. However, the original Cox MAZE although extremely successful in treating atrial fibrillation and decreasing the incidence of strokes was not performed widely because of complexity and invasiveness of the procedure. A variety of alternative energy based curative ablation strategies are now available for more minimally invasive therapeutic management of atrial fibrillation (AF). In this communication, we report our clinical experience in AF therapy utilizing laser energy ablation technology.

Methods: Fifty two consecutive AF patients underwent concomitant or isolated ablation prior to any coexisting cardiac procedures that included CABG (coronary artery bypass surgery, MV (mitral valve) or AV (aortic valve) repairs. All patients had an epicardially based ablation pattern with basic lesions being en bloc box type pulmonary vein isolation which included the antral surface of the left atrium, directed ganglionectomies of the the right anterior and inferior ganglions, posteriomedial ablation of the IVC ( inferior vena cava), and a right isthmus ablation. Twenty seven patients had ligation of their left atrial appendage, 14 patients had resection of the ligament of Marshall, and three patients had endocardial placed lesions of a mitral annular connecting type lesion. In order to maintain the patients in normal sinus rhythm (NSR), electrical cardioversion and anti-arrhythmic drugs were employed as required.

Results: At a median follow-up of 250 days, 44 of the total 52 patients (84.6%) exhibited NSR.. No complications or mortality were reported due to the laser procedure.

Conclusion: Laser ablation was successfully and safely used for endocardial and epicardial AF ablation concomitant to other cardiovascular procedures and in the lone atrial fibrillation treatment utilizing a two port thoracoscopic approach.

Thursday, June 18, 2009

Esophageal Dilatation Post – Gastric Banding And Catheter Ablation For Atrial Fibrillation: A Case Report

Citation : Simon Townsend, Andrew James, Nicholas Daunt MBBS, Karen P. Phillips MBBS.Esophageal Dilatation Post – Gastric Banding and Catheter Ablation for Atrial Fibrillation: A Case Report .JAFIB.2009 June;Volume 1 Issue(7): 451-453.

Esophageal injury is a potential serious complication of catheter ablation for atrial fibrillation. We report a case of significant esophageal dilatation following previous laparascopic gastric banding in a patient with permanent atrial fibrillation undergoing a pulmonary vein isolation procedure.

The position of the esophagus was delineated on the integrated CT navigational map and on fluoroscopy by placement of an esophageal thermistor probe. Radiofrequency energy was delivered through an open irrigated tip catheter and titrated to maximum 25W and 40°C for lesions applied to the left atrial posterior wall. Esophageal temperature rises were only seen in association with lesions applied to the right inferior pulmonary vein and energy applications here were limited to avoid esophageal temperatures >38.5°C.

Masquerading Tachycardia

Citation : Yaariv Khaykin MD, Zaev Wulffhart MD, Bonnie Whaley CCT, Atul Verma MD.Masquerading Tachycardia .JAFIB.2009 June;Volume 1 Issue(7): 447-450.

Mrs. BW is a 69 year old previously well woman with history of palpitations. Extensive workup showed no evidence of structural heart disease. Her baseline ECG was unremarkable. She was clinically documented to have narrow complex tachycardia. In tachycardia her ECG showed brief bursts of ectopic atrial activity with “saw-tooth” appearance in the inferior leads (Figure 1, Panel A) alternating with lesser amplitude p-waves positive in the inferior leads and in V1 (Figure 1, Panel B). During electrophysiology study a quadripolar catheter was placed at the right ventricular apex, a decapolar catheter in the coronary sinus, a duodecapolar catheter around the tricuspid annulus and a quadripolar catheter at the His bundle position.

The Phrenic Nerve and Atrial Fibrillation Ablation Procedures

Citation : Jennifer A. Mears, BS, Nirusha Lachman, PhD, Kevin Christensen, Samuel J. Asirvatham, MD, FACC, FHRS.The Phrenic Nerve and Atrial Fibrillation Ablation Procedures .JAFIB.2009 June;Volume 1 Issue(7): 430-446.

Radiofrequency ablation is increasingly used as an option to optimally manage patients with symptomatic atrial fibrillation. Presently, ablationists strive to improve success rates, particularly with persistent atrial fibrillation, while simultaneously attempting to reduce complications. A well-recognized complication with atrial fibrillation ablation is injury to the phrenic nerve giving rise to diaphragmatic paresis and patient discomfort.

Phrenic nerve damage may occur when performing common components of atrial fibrillation ablation including pulmonary and superior vena caval isolation. The challenge for ablationists is to successfully target the arrhythmogenic substrate while avoiding this complication. In order to do this, a thorough knowledge of phrenic nerve anatomy, points in the ablation procedure where nerve damage is more likely, and an understanding of the presently utilized techniques to avoid this complication is required.

In addition, when this complication does arise, prompt recognition of its occurrence, knowledge of the natural history, and available methods for management are needed.

In this review, we discuss the underlying anatomic principles, techniques of avoiding phrenic nerve damage, and presently available methods of diagnosing and managing this complication.

Atrial Fibrillation Complicating Congestive Heart Failure: Electrophysiological aspects and its Deleterious effect on Cardiac Resynchronization therap

Citation : Osmar Antonio CenturiĆ³n, MD, PhD, FACC.Atrial fibrillation complicating congestive heart failure: Electrophysiological aspects and its deleterious effect on cardiac resynchronization therapy .JAFIB.2009 June;Volume 1 Issue(7): 417-429.

More successful recognition and treatment of cardiovascular risk factors and diseases continues to decrease mortality and increase the proportion of elderly population. Therefore, there are more people with increased risk of developing heart failure and atrial fibrillation in the course of their lives. Atrial fibrillation (AF) can complicate the course of congestive heart failure (HF) leading to acute pulmonary edema. The prevalence of AF, in patients with heart failure, increases with the severity of the disease, reaching up to 40% in advanced cases. In these HF patients, AF is an independent predictor of morbidity and mortality increasing the risk of death and hospitalization. Despite the excellent results obtained with different drugs, the optimal medical treatment can fail in the intention to improve symptoms and quality of life of patients with severe HF. Thus, the necessity to use cardiac devices emerges facing the failure of optimal medical treatment in order to achieve hemodynamic improvement and correction of the physiopathological alterations. Cardiac resynchronization therapy (CRT) can reduce the interventricular and intraventricular mechanical dissynchrony in HF patients. It has been shown that CRT increases the left ventricular filling time, decreases septal disquinesia, mitral regurgitation, and left ventricular volumes allowing a hemodynamic improvement. However, the development of AF in this setting can avoid the beneficial effects of CRT. Therefore, this manuscript will review the available data on this topic to determine what can be done in the event of an AF complicating congestive HF in CRT patients.

Atrial Remodeling and Atrial Fibrillation: Mechanistic Interactions and Clinical Implications

Citation : Bandar Al Ghamdi, MD, Walid Hassan, MD, FACP, FACC, FCCP, FAHA.Atrial Remodeling And Atrial Fibrillation: Mechanistic Interactions And Clinical Implications .JAFIB.2009 June;Volume 1 Issue(7): 395-416.

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. The prevalence of AF increases dramatically with age and is seen in as high as 9% of individuals by the age of 80 years. In high-risk patients, the thromboembolic stroke risk can be as high as 9% per year and is associated with a 2-fold increase in mortality. Although the pathophysiological mechanism underlying the genesis of AF has been the focus of many studies, it remains only partially understood. Conventional theories focused on the presence of multiple re-entrant circuits originating in the atria that are asynchronous and conducted at various velocities through tissues with various refractory periods. Recently, rapidly firing atrial activity in the muscular sleeves at the pulmonary veins ostia or inside the pulmonary veins have been described as potential mechanism,. AF results from a complex interaction between various initiating triggers and development of abnormal atrial tissue substrate. The development of AF leads to structural and electrical changes in the atria, a process known as remodeling. To have effective surgical or catheter ablation of AF good understanding of the possible mechanism(s) is crucial. Once initiated, AF alters atrial electrical and structural properties that promote its maintenance and recurrence. The role of atrial remodeling (AR) in the development and maintenance of AF has been the subject of many animal and human studies over the past 10-15 years. This review will discuss the mechanisms of AR, the structural, electrophysiologic, and neurohormonal changes associated with AR and it is role in initiating and maintaining AF. We will also discuss briefly the role of inflammation in AR and AF initiation and maintenance, as well as, the possible therapeutic interventions to prevent AR, and hence AF, based on the current understanding of the interaction between AF and AR.

Evolution of Paroxysmal Atrial Fibrillation to Persistent or Permanent Atrial Fibrillation: Predictors of Progression

Citation : Jayasree Pillarisetti, Akshar Patel, Kenneth Boc, Sudharani Bommana, Youssef Sawers, Subbareddy Vanga, Hari Sayana, Warren Chen, Jayanth Nath, James Vacek, Dhanunjaya Lakkireddy. Evolution of Paroxysmal Atrial Fibrillation to Persistent or Permanent Atrial Fibrillation: Predictors of Progression .JAFIB.2009 June;Volume 1 Issue(7): 388-394.

Introduction – Paroxysmal atrial fibrillation (PAF) eventually progresses to persistent and permanent AF. The predictors of progression from PAF to persistent and permanent AF are poorly understood.
Methods – Electronic medical records of 437 patients with PAF were reviewed in a retrospective cohort study. Patients were followed in time and progression to persistent/permanent AF was recorded. Demographic, clinical and echocardiographic information was collected. A logistic regression analysis was performed to identify predictors of progression to persistent/permanent AF.
Results – Over a mean duration of 57.3±55.9 months, 32.4% of patients progressed to persistent/permanent AF. Mean age of the population was 67.9±13.4 years with 57% males and 92% Caucasian. Univariate analysis identified higher body higher mass index (BMI), cardiomyopathy, diabetes, valvular heart disease (VHD), larger left atrial size (LA) and higher pulmonary artery pressure as predictors of progression. Multivariate logistic regression analysis larger left atrial size (OR 1.46, CI 1.05-2.04, P 0.002), cardiomyopathy (OR 2, CI 1.1- 3.3, P 0.003), and moderate to severe valvular heart disease (OR 3.3, CI 1.4-5, P 0.008) as significant predictors of progression to persistent/permanent AF.
Conclusion – Our study shows that PAF patients with larger LA, valvular heart disease and cardiomyopathy predict progression of PAF to persistent/permanent AF. Higher BMI and cardiomyopathy predicted progression to persistent AF while larger LA size and VHD predicted progression to permanent AF.

Friday, April 10, 2009

EDC Administrator

Desired Profile:
Desirable degrees: A Bachelors or Master degree or equivalent in Computer science, a Life science or equivalent.
Languages: English, excellent spoken and written
Experience: At least 1 year in the biotechnology or pharmaceutical industry, preferably with direct clinical database system administration experience.
Possess the following knowledge/experience:
Good computer skills
Relational databases
Understands clinical data
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Problem solving skills
Accurate worker with attention to relevant details
Ability to set and meet deadlines
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Experience:1 - 3 Years
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Location:Hyderabad / Secunderabad
Contact:Novartis Healthcare Pvt Ltd

Thursday, April 9, 2009

Assessing Patient Management and Outcomes in Atrial Fibrillation: Does your health insurance plan know more than your doctor?

Citation :Sanjeev Saksena, April Slee.Assessing Patient Management And Outcomes In Atrial Fibrillation: Does Your Health Insurance Plan Know More Than Your Doctor? .JAFIB.2009 April;Volume 1 Issue(6): 383-387.

Assessing the landscape of any major public health challenge and the effectiveness of existing health care practices is a difficult proposition in any circumstance for health care planners and providers. To do so with relatively current health care data has not been a feasible reality. Too often health care planners have been relegated to use of venerable but dated clinical information. Equally often, clinical trial data collected for a purpose other than outcomes research have been extrapolated well beyond their original intent. The field of atrial fibrillation is no exception. The durable and well-reported Framingham study data have provided modern day framework for a natural history base of the disease over many decades . More recent analyses have shown worldwide similarity in patterns and increasing prevalence . The cascade of anticoagulant trials in the nineties with their metanalyses and methodology also provided outcome endpoints that have been widely used as a benchmark . More recently, NIH clinical trials such as the AFFIRM trial have provided some outcomes analyses . Yet these tools provide information that may have been captured some time ago and significantly lag current medical experiences and practice.

Scenes from a CFAE: Complex Fractionated Atrial Electrogram Map in a Woman with Longstanding Persistent Atrial Fibrillation Following Mechanical Mitra

Citation :James C. Hansen, Abraham G. Kocheril.Scenes from a CFAE: Complex Fractionated Atrial Electrogram Map in a Woman with Longstanding Persistent Atrial Fibrillation Following Mechanical Mitral Valve Replacement .JAFIB.2009 April;Volume 1 Issue(6): 366-369.

Case: A 62-year-old woman was referred for atrial fibrillation (AF) ablation. She had longstanding persistent AF for 8 years since mechanical mitral valve replacement for rheumatic heart disease.

EPS: A strategy of substrate-based ablation targeting areas of complex fractionated atrial electrograms (CFAE) was pursued. These sites were identified by inspection of electrograms and verified with software-based electrogram analysis, with the left atrial roof demonstrating the highest density of CFAE sites. Successful catheter ablation was performed. The patient has remained free of recurrence over 4 months of follow-up.

Discussion: This case presents a successful ablation procedure using the emerging strategy of CFAE-targeted ablative lesions. Given the patient’s longstanding persistent AF and mechanical mitral valve, the high density of CFAE sites on the left atrial roof was an unexpected finding. Analysis for CFAE sites guided the procedure in a direction that might otherwise not have been undertaken, leading to a successful ablation.

Ectopic Triggers of Superior Vena Cava in Atrial Fibrillation

Citation :Jayasree Pillarisetti, Wallace Ray, Dhanunjaya Lakkireddy.Ectopic Triggers of Superior Vena Cava in Atrial Fibrillation .JAFIB.2009 April;Volume 1 Issue(6): 363-365.

Superior vena cava (SVC) triggers constitute 6-8% of non-pulmonary vein (PV) foci that initiate atrial fibrillation (AF). Since SVC cardiomyocytes originate from the right sinus horn they possess enhanced automacity and after-depolarization leading to arrhythmogenicity. In a recent study by Arruda et al. 12% of patients had SVC triggers and empiric adjunctive isolation of SVC-right atrium (RA) along with PV isolation resulted in higher long term success rate than the group that underwent PVI alone. They demonstrated that adjunctive isolation of SVC along with PVI is a safe and feasible strategy for ablation of AF.

JAFIB : A comprehensive resource for Afib ....

Citation :Andrea Natale.JAFIB : A comprehensive resource for Afib .... .JAFIB.2009 April;Volume 1 Issue(6): 362.

On this anniversary issue, I wanted to congratulate you and thank you for making the Journal of Atrial Fibrillation (JAFIB) a great success. With specific focus on atrial fibrillation we were able to surpass our targets for the past year with your active participation and support. With continued progress made in the diagnostic and therapeutic tools in treating AF, this past year has witnessed a period of consolidation and introspection of what we have been doing. We have come to agree that pulmonary veins are a major source arrhythmia initiation and maintenance and should be the primary target for isolation.

Biatrial, 3-Dimensional Mapping of Human Atrial Fibrillation: Methodology and Clinical Observations

Citation :Nicholas D. Skadsberg, Rangadham Nagarakanti, Sanjeev Saksena.Biatrial, 3-Dimensional Mapping of Human Atrial Fibrillation: Methodology and Clinical Observations .JAFIB.2009 April;Volume 1 Issue(6): 370-382.

Atrial fibrillation (AF), the most common arrhythmia in clinical practice, accounts for nearly one third of all hospitalizations for cardiac rhythm disturbances. Consequently, this has stimulated intense investigative interest in the development of effective therapeutic options. However, the electrophysiologic (EP) mechanisms of this arrhythmia have been long debated and remain unclear. This has limited the development of effective management strategies. Previous studies have shown the progressive remodeling associated with AF, initially believed to be functional and electrical in nature, now has structural and contractile impact [1]. It is increasingly clear that the latter two processes play an increasingly important role in the recurrence and persistence of AF [2-4]. In an effort to clarify AF mechanisms, numerous experimental models have been developed. Their relationship to human mechanisms remains poorly defined. Direct mapping of human AF has been attempted but is still in its evolution. It is the purpose of this commentary to review existing mapping techniques and propose a new approach for mapping of human AF.
This review describes a new technique for mapping of human atrial fibrillation in the electrophysiologic laboratory on a beat to beat basis. It permits biatrial mapping and high resolution mapping in the atrium of interest. It has been used routinely in clinical practice and clinical observations and experience are presented.

Atrial Fibrillation: The New Epidemic of the Ageing World

Citation :Wilbert S. Aronow, Maciej Banach.Atrial Fibrillation: The New Epidemic of the Ageing World .JAFIB.2009 April;Volume 1 Issue(6): 337-361.

The prevalence of atrial fibrillation (AF) increases with age. As the population ages, the burden of AF increases.AF is associated with an increased incidence of mortality, stroke, and coronary events compared to sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to reduce immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in elderly patients , ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily.

Genetics and Sinus Node Dysfunction

Citation :Eyal Nof, Michael Glikson and Charles Antzelevitch.Genetics and Sinus Node Dysfunction .JAFIB.2009 April;Volume 1 Issue(6): 328-336.

Sinus node dysfunction (SND) is commonly encountered in the clinic. The clinical phenotype ranges from asymptomatic sinus bradycardia to complete atrail standstill. In some cases, sinus bradycardia is associated with other myocardial conditions such as congential abnormalities, myocarditis, dystrophies, cardiomyopathies as well as fibrosis or other structural remodeling of the SA Node. Although there are many etiologies for symptomatic slow heart rates, the only effective treatment available today is the implementation of a pacemaker. The predominant ion channel currents contributing to the pacemaker activity in the sinoatrail node (SAN) include currents flowing through hyperpolarization-activated, cyclic nucleotide-gated (HCN) channels, L- type Ca, T- type Ca, delayed rectifier K, and acetylcholine (ACh)-activated channels.

Is Cryo A Better Energy Source Than Radiofrequency For AF Ablation In Preventing Esophageal Injury?

Citation :Pawan K. Arora, James Hansen, Rakesh Latchamsetty, Boaz Avitall.Is Cryo A Better Energy Source Than Radiofrequency For AF Ablation In Preventing Esophageal Injury? .JAFIB.2009 April;Volume 1 Issue(6): 321-327.

Atrial fibrillation (AF) is by far the most common tachyarrhythmia in humans. Prevalence of this rhythm disorder is 0.3-0.4% of adult population and increases with age from 2-4% in people over the age of 60 to 11.6 % in those over the age of 75 . In recent years, increasing number of patients are subjected to catheter ablation in an effort to cure AF. It has been shown that a successful AF ablation results in improved quality of life as well as left ventricular function when compared to other treatment modalities including pharmacologic treatment and pacemaker devices . Most ablation strategies today target electrical isolation of the pulmonary veins (PVs), which are believed to be the site of major foci triggering AF .

Predictors of Success After a First Circumferential Pulmonary Vein Isolation for Atrial Fibrillation

Citation :T De Potter, R Tavernier, D Devos, K Van Beeumen, M Duytschaever.Predictors of Success After a First Circumferential Pulmonary Vein Isolation for Atrial Fibrillation .JAFIB.2009 April;Volume 1 Issue(6): 311-320.

Background: To identify and characterise pre-procedural and procedural parameters which predict maintenance of sinus rhythm after a first circumferential pulmonary vein isolation (CPVI) for recurrent atrial fibrillation (AF).

Methods: 100 patients (54±10 yrs) undergoing CARTO-guided CPVI for symptomatic drug refractory, paroxysmal or shortstanding persistent AF were studied. The endpoint was complete electrical isolation within the encircled regions. 3D left atrial (LA) volume was measured by CARTO geometry. Follow-up examinations (symptoms, ECG, 24-hour ECG recording) were performed at 1 and 3 months and every 3 months thereafter.

Results: After the first CPVI, 71 patients (71%) were free of AF without antiarrhythmic drug therapy (follow up:28±11 months). The only independent and significant predictors for freedom of AF after the first CPVI were duration of AF history and 3D LA volume (p<0.05). However, a significant overlap in durations of AF history and 3D LA volumes between failures and successes was observed.

Conclusions: (1) Using the “circumferential pulmonary vein isolation” approach, the first catheter ablation leads to resolution of arrhythmia in »70% of symptomatic AF patients. (2) Independent predictors for freedom of AF after initial CPVI are duration of AF history and 3D LA volume. (3) Due to considerable overlap between failures and successes, these parameters can not be used to identify patients who should not undergo CPVI or in whom an additional ablation beyond CPVI is required. On the other hand, our results do suggest that an ablation strategy early in the course of AF disease can influence successful outcome.

Wednesday, February 4, 2009

14th Annual Boston Atrial Fibrillation Symposium Proceedings – Technology Round Up

Citation :Dhanunjaya Lakkireddy.14th Annual Boston Atrial Fibrillation Symposium Proceedings – Technology Round Up .JAFIB.2009 Feb;Volume 1 Issue(5): 304-307.

What started off as a small, cozy meeting of electrophysiologists thinking about atrial fibrillation (AF) evolved into a major annual program that draws more audience every year. Thanks to the vision of Dr. Jeremy Ruskin (Massachussets General Hospital, Boston) who started this program and continues to direct it very effectively to this day. Over the last few years, industry has used this as a good platform to showcase some of their latest technology in AF therapy. Several products ranging from radiation protection devices to most advanced mapping and ablation systems have been displayed at the Seaport Hotel.

Review on "Atrial Fibrillation Progression: New Insight in The Natural History of This Arrhythmia"

Citation :Sanjay Dixit.Review on "Atrial Fibrillation Progression: New Insight in The Natural History of This Arrhythmia" .JAFIB.2009 Feb;Volume 1 Issue(5): 301-303.

The past decade has witnessed a dramatic shift in our approach to the management of atrial fibrillation (AF) . This can largely be attributed to the advent of catheter ablation therapy which has proven to be significantly more efficacious in achieving arrhythmia control than antiarrhythmic drugs . However, despite these developments, there is paucity of data on the natural history of this arrhythmia and studies that have been conducted so far to evaluate this aspect of AF behavior, are mostly retrospective . Thus, there is a growing need to assess AF progression on a prospective basis.

Review on "High-Density Mapping of Atrial Fibrillation in Humans: Relationship Between High-Frequency Activation and Electrogram Fractionation"

Citation :Yaariv Khaykin.Review on "High-Density Mapping of Atrial Fibrillation in Humans: Relationship Between High-Frequency Activation and Electrogram Fractionation" .JAFIB.2009 Feb;Volume 1 Issue(5): 298-300.

Catheter ablation has rapidly gained acceptance as a mainstay of therapy for many symptomatic patients with atrial fibrillation since the original publication by the Bordeaux group . Early on it became apparent that in most patients with paroxysmal AF, the arrhythmia was initiated by focal firing in the pulmonary veins. Ablation focused on elimination of such triggers and was largely limited to patients who would stay in sinus rhythm long enough to allow successful mapping within the pulmonary veins. As this was time consuming and was associated with high risk of developing pulmonary vein stenosis, ablation lesions were moved further and further away from the sources of focal firing with co-development of Circumferential Pulmonary Vein Ablation (CPVA) aiming to encompass pulmonary vein ostia with circular lesions without verification of conduction block and Segmental Pulmonary Vein Isolation evolving into Pulmonary Vein Antrum Isolation with the targeted area similar to that in CPVA but with requisite documentation of entry and / or exit block of conduction.

Anticoagulation During AF Ablation: The Balance Between Thromboembolism And Bleeding

Citation :Jennifer A. Mears, Samuel J. Asirvatham.Anticoagulation during AF Ablation: The Balance Between Thromboembolism and Bleeding .JAFIB.2009 Feb;Volume 1 Issue(5): 285-297.

Radiofrequency ablation for atrial fibrillation is being increasingly used to treat patients with symptomatic arrhythmia. The procedure is complex and associated with significant complications including thromboembolism, stroke, and bleeding.

Despite significant advances in catheter design, online cardiac imaging, and greater operator experience, both stroke and major vascular complications continue to be problematic.

Increasing the duration and intensity of anticoagulation has been the primary modality used to decrease thromboembolism. However, these measures increase the likelihood and severity of bleeding-related complications. The optimal method of anticoagulation along with the adjunctive use of technology to decrease vascular complications and mechanically prevent cerebral embolization is unknown.

In this paper, we review the present methods used by ablationists to decrease the likelihood of thromboembolism during atrial fibrillation. We then describe methods used to decrease bleeding and vascular complications at access sites as well as cardiac perforation. We briefly discuss newer techniques to decrease endovascular complications including epicardial ablation and the use of temporarily implanted vascular protection devices.

Finally, we describe the best option or combination of approaches that attempt to balance the risks of thromboembolism and bleeding during AF ablation.

Are Balloon Based Strategies Better Than Conventional Radiofrequency Catheter Ablation: Exploring New Frontiers In The Treatment Of AtrialFibrillation

Citation : Alexander Fuernkranz, Julian Chun, Boris Schmidt, Karl-Heinz Kuck, Feifan Ouyang.Are balloon based strategies better than conventional radiofrequency catheter ablation: Exploring new frontiers in the treatment of atrial fibrillation .JAFIB.2009 Feb;Volume 1 Issue(5): 279-284.

Paroxysmal atrial fibrillation can be eliminated with continuous circular linear lesions around the pulmonary veins using radiofrequency ablation. Due to the technical complexity of this procedure balloon-based devices have been developed to simplify pulmonary vein isolation. Cryoballoon ablation provides excellent safety and is technically less demanding when compared to radiofrequency catheter ablation in selected patients. In this review, advantages as well as drawbacks of this emerging technology in relation to standard catheter ablation are discussed.

Cardiovascular Risk Factors and Atrial Fibrillation: What is the Link?

Citation :Yaariv Khaykin.Cardiovascular Risk Factors and Atrial Fibrillation: What is the Link? .JAFIB.2009 Feb;Volume 1 Issue(5): 277-278.

Atrial fibrillation is a common cardiac arrhythmia. It is well known to occur in older patients with comorbid conditions such congestive heart failure and ischemic heart disease . In these otherwise sick individuals it is associated with higher long term morbidity and mortality .In their paper published in the February issue of JAFIB, Dr. Barrios and colleagues further examine the association between atrial fibrillation, classical coronary risk factors, proven cardiovascular preventive therapies and end-organ damage in 2024 patients with documented hypertension and coronary heart disease.

Accurate Detection Of Left Atrial Thrombus Prior To Atrial Fibrillation Ablation In Patients With Therapeutic Anticoagulation: Does Transesophageal

Citation :Dhanunjaya Lakkireddy.Accurate Detection Of Left Atrial Thrombus Prior To Atrial Fibrillation Ablation In Patients With Therapeutic Anticoagulation: Does Transesophageal Echocardiography Beat Conventional Wisdom? .JAFIB.2009 Feb;Volume 1 Issue(5): 308-310.

Atrial fibrillation (AF) significantly increases the risk of left atrial (LA) thrombus and systemic thromboembolism . Screening transesophageal echo (TEE) to rule out left atrial thrombus has become standard of care over the years . Conventional thinking of therapeutic anticoagulation for 4-6 weeks prior to cardioversion may not reduce the risk of left atrial thrombus completely. Left atrial thrombi can be seen on 2-9% of screening TEEs in AF patients with various levels of anticoagulation . Radiofrequency ablation of atria with pulmonary vein isolation (PVI) with or without various additional ablative techniques has evolved into very important strategy in the treatment of patients with AF .

QT Prolongation Following Ectopic Beats: Initial Data Regarding the Upper Limit of Normal with Possible Implications for Antiarrhythmic Therapy

Alyssa J. Reiffel, James A. Reiffel.QT Prolongation Following Ectopic Beats: Initial Data Regarding the Upper Limit of Normal with Possible Implications for Antiarrhythmic Therapy and Concealed (Unexpressed) Long QT .JAFIB.2009 Feb;Volume 1 Issue(5): 270-276.

Ectopic beats are frequently associated with morphologic repolarization alterations of ensuing sinus beats. Less is known about repolarization duration alterations of post-ectopic sinus beats. In one patient who developed long QT and torsades de pointes upon exposure to a class III antiarrhythmic drug, and was later genotyped as being a carrier for long QT syndrome (LQTS) type 1, review of a pre-drug Holter monitor study revealed marked QT prolongation of post-ectopic sinus beats. In wondering whether this might be a common clue to “concealed” unexpressed LQTS, we realized that we must first characterize the range of post-ectopic QT prolongation present in normals. Prolongation beyond the upper limit of this range might then raise suspicion of possible LQTS and alter the antiarrhythmic drug selection process for the suppression of atrial fibrillation or other arrhythmias. Accordingly we performed this study to determine the presence/degree of repolarization prolongation in normal individuals following premature ectopic impulses. We found that QT prolongation is common in post ectopic sinus beats but that the uncorrected QT interval of post-ectopic beats in normals never exceeded 480 ms in duration which was much shorter than that seen (510-590 ms) in our gene carrier.

Atrial fibrillation and coronary heart disease: fatal attraction

Citation :Vivencio Barrios, Carlos Escobar, Rocio Echarri.Atrial fibrillation and coronary heart disease: fatal attraction .JAFIB.2009 Feb;Volume 1 Issue(5): 262-269.

In this manuscript, the profile and clinical management of hypertensive patients with chronic ischemic heart disease and atrial fibrillation (AF) is examined and whether high heart rate is associated with a different profile is determined. CINHTIA was a cross-sectional and multicenter survey aimed to define the clinical profile of hypertensive patients with chronic ischemic heart disease daily attended in Spain. Blood pressure, LDL-cholesterol and diabetes control rates were established according to ESH-ESC 2003, NCEP-ATP III and ADA 2005 guidelines, respectively. Out of the 2024 patients, 338 (16.7%) exhibited AF. The group of patients with AF was older and with higher prevalence of diabetes, organ damage and cardiovascular disease. Blood pressure (41.8% vs 34.5%, p=0.014) and diabetes (28.5% vs 20.9%,p=0.044) were worse controlled in patients with AF, with a trend to a lower control of LDL-cholesterol (31.2% vs 26.8%, p=0.093). When distributing patients with AF according to heart rate, except for smoking, left ventricular hypertrophy and peripheral arterial disease that were more frequent in those with higher heart rate, no significant differences were found in other risk factors or organ damage between groups. Blood pressure, glycemia and LDL-cholesterol were worse controlled in the subgroup with highest heart rate. In clinical practice, hypertensive patients with chronic ischemic heart disease and AF have a bad prognosis not only due to a worse clinical profile, but also due to lower risk factors control rates. In contrast with patients at sinus rhythm, higher heart rate was a weaker predictor of outcomes in subjects with AF.

Presence of left atrial appendage thrombus in patients presenting for left atrial ablation of atrial fibrillation despite pre-operative anticoagulatio

Citation : Joseph P. de Bono, Sacha Bull, John Paisey, David Tomlinson, Kim Rajappan, Yaver Bashir, Harald Becher and Timothy R Betts.Presence of left atrial appendage thrombus in patients presenting for left atrial ablation of atrial fibrillation despite pre-operative anticoagulation. .JAFIB.2009 Feb;Volume 1 Issue(5): 257-261.


One of the recognised complications of left atrial ablation for atrial fibrillation (AF) is stroke. Left atrial (LA) thrombus, which may be dislodged by catheter manipulation, is an absolute contraindication to ablation. It is unclear whether imaging of the left atrial appendage (LAA) by transesophageal echo (TEE) is mandatory to exclude LA clot prior to ablation, particularly in “low-risk” patients with paroxysmal AF and normal left ventricular (LV) function.

Methods and results:

We carried out a retrospective analysis of pre-ablation TEE in patients presenting for ablation of AF. All patients received a minimum of 4 weeks therapeutic anticoagulation before stopping oral anticoagulants 3 days before their procedure. Images from 244 ablation procedures carried out in 148 patients were examined, including 106 patients with paroxysmal AF and normal LV function.

Despite at least 4 weeks of pre-operative therapeutic anticoagulation with Coumadin (INR>2.0), LAA thrombus was identified in 4 patients (2.7%). These included 2 patients with paroxysmal AF and normal LV function, although both had a high arrhythmia burden. The thrombi regressed with intensification of anticoagulation.


In conclusion, pre-operative imaging of the LAA remains advisable to exclude thrombus prior to ablation for AF even in patients with paroxysmal AF and normal LV function.

Thursday, January 8, 2009

Blue Cross Blue Shield Calls Atrial Fibrillation Ablation Investigational And Denies Coverage!!

Kansas City, January 7, 2008

BlueCross BlueShield of Kansas City has sent several of its insurance holders a notification saying that Atrial Fibrillation ablation is no longer a covered benefit in their insurance program. The letter sent out by Bluecross Blueshield quotes – “ It has come to our attention that we may have paid for a procedure called Pulmonary vein isolation for you in the past six months that is considered ‘investigational’ according to our corporate medical policy. Pulmonary vein isolation is used to treat atrial fibrillation. Because the effectiveness of this service has not been established, it is our policy to not cover it for our members.” The notification went on to say that the above mentioned policy was effective May 1, 2008.

The underlying circumstances that prompted this major health insurance company to take this action were unclear. Pulmonary vein isolation otherwise known as the AF ablation is one of the most extraordinary advancement that the field of electrophysiology has made in the last decade. Discovery of pulmonary veins as the major contributors to the initiation of atrial fibrillation has led to this landmark procedure that changed the way physicians treated patients with this disabling heart rhythm condition. This heart rhythm condition affects at least 4-5 % population and its incidence increases significantly with ageing. Pulmonary vein isolation in combination with ablation of the other areas of the atria (upper chambers of the heart) has proven to be very successful in abating AF anywhere from 60 - 90% of patients depending on their underlying conditions. This procedure has been recognized as standard of care in eligible patients by the worlds leading cardiovascular societies including – The American Heart Association, American Cardiology of Cardiology, Heart Rhythm Society and European Society of Cardiology.

Currently the Center for Medicare Services (CMS) currently covers this particular procedure. Since the initial experience of pulmonary vein isolation by Michel Haissaguerre’s group from Bordeaux, France in the New England Journal of Medicine article in 1998, more than 1400 articles have been published in major peer reviewed journals. This is the most well studied subject than any other heart rhythm condition known to the medical field. AF ablation has changed the lives of millions of people around the world who would have otherwise been left on warfarin and heart rate/rhytm control medications for the rest of their lives. The one time upfront costs of this procedure are definitely higher than a single electrical cardioversion (external shock) with drug therapy. The cumulative costs of treating this arrhythmia with conventional lifelong drug therapy including all the patient visits to the emergency rooms, urgent cares, electrical cardioversions, blood tests, echocardiographic tests and hospitalizations were proven to be significantly higher than AF ablation. The devastating effects of stroke and heart failure (from tachycardia mediated cardiomyopathy) are worth taking into account in these patients. There are several published reports that support the superiority of AF ablation over drug therapy from an economic stand point.

Obviously, this latest move by BlueCross BlueShield may save them millions of dollars but denies hundreds of eligible patients their fundamental right to appropriate treatment. Unilateral decisions by insurance companies to deny particular tests and procedures have occurred in the past and AF ablation is a new addition to the list. Situations like this clearly challenge the value and credibility of clinical guidelines put out by the scientific organizations.