Journal of Atrial Fibrillation Blog

Septic Shock due to Implantable Cardiac Defibrillator Related Infection

2011-03-21T03:25:00.001-07:00

Citation : David Palmer, Aleem Khand.Septic Shock due to Implantable Cardiac Defibrillator Related Infection .JAFIB.2011 February;Volume 2 Issue(4): 888-890.

Infection is an important complication of cardiac device implantation. We report the case of a 61 year old patient presenting with septic shock caused by cardiac device infection (CDI) three-weeks after device implantation. At initial presentation, there was an absence of both localising signs and echocardiographic evidence of CDI. Later, Staphylococcus aureus was cultured from blood and the pre-pectoral pocket. 48 hours after admission the device and leads were explanted in theatre by simple traction. Despite appropriate antibiotics and full supportive care (including haemofiltration, ventilation and inotropic support), the patient died on day six. Cardiac device infection may present with septic shock in the absence of localising features. A high index of suspicion is required, particularly for early CDI.

Role of Remote Navigation Systems in AF Ablation

2011-03-21T03:20:00.000-07:00

Citation : Boris Schmidt, Britta Schulte-Hahn, Bernd Nowak, Verena Windhorst, Kyoung Ryul Julian Chun.Role of Remote Navigation Systems in AF Ablation .JAFIB.2011 February;Volume 2 Issue(4): 881-887.

During the past decade atrial fibrillation (AF) ablation has developed from being an experimental treatment option to an evidence based therapy implemented in current guidelines. Irrigated radiofrequency current guided ablations remain the golden standard of pulmonary vein isolation (PVI) procedures. Although practiced more frequently, it remains a demanding procedure requiring skilful operators. Novel technologies such as balloon based catheters or remote navigation (RN) systems have been developed to overcome the pitfalls of manual ablation procedures.

The Cost of Thromboembolic Events and their Prevention among Patients with Atrial Fibrillation

2011-03-21T03:16:00.000-07:00

Citation : Thomas Davidson, Magnus Husberg, Magnus Janzon, Lars-Ake Levin. The Cost of Thromboembolic Events and their Prevention among Patients with Atrial Fibrillation .JAFIB.2011 February;Volume 2 Issue(4): 870-880.

Aim: Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. People with AF have a significantly increased risk of thromboembolic events, including stroke, and the main treatment is therefore aimed at preventing thromboembolic events via anticoagulation with warfarin or acetylsalicylic acid. However, the development of new anticoagulation treatments has prompted a need to know the current cost of AF-related thromboembolic events, for future cost-effectiveness comparisons with the existing treatments. In this study, we estimated the cost of thromboembolic events and their prevention among Swedish AF patients in 2010.

Methods: The relevant costs were identified, quantified, and valued. The complications included were ischaemic and haemorrhagic stroke, gastrointestinal bleeding, and other types of major bleeding caused by AF. Treatments intended to lower the risk of ischaemic stroke were also included. A societal perspective was used, including productivity loss due to morbidity. Patients with a CHADS2 score of 1 or higher were included.

Results: Among the 9 340 682 inhabitants of Sweden, there are 118 000 patients with AF and at least one more risk factor for stroke, comprising 1.26% of the population. Of these patients, 43.3% are treated with warfarin, 28.3% use acetylsalicylic acid, and 28.3% are assumed to have no anticoagulation treatment. The cost of AF-related complications and its prevention in Sweden was estimated at €437 million for 2010, corresponding to €3 712 per AF patient per year. The highest cost was caused by stroke, and the second highest by the cost of monitoring the warfarin treatment. As the prevalence of AF is expected to increase in the future, AF-related costs are also expected to rise.

Conclusion: Thromboembolic events cause high costs. New, easily-administered treatments that could reduce the risk of stroke have the potential to be cost-effective.

Cardiac Image Registration: Rotational Error Correction and Gated Stabilization for Cardiac Motion

2011-03-21T03:12:00.000-07:00

Citation : Jasbir Sra.Cardiac Image Registration: Rotational Error Correction and Gated Stabilization for Cardiac Motion .JAFIB.2011 February;Volume 2 Issue(4): 856-869.

Background: Dynamic motion of the heart due to cardiac and respiratory cycles, and rotation from varying patient positions between imaging modalities, can cause errors during cardiac image registration. This study used phantom, patient and animal models to assess and correct these errors.

Methods and Results: Rotational errors were identified and corrected using different phantom orientations. ECG-gated fluoro images were aligned with similarly gated CT images in 9 patients, and accuracy assessed during atrial fibrillation (AF) and sinus rhythm. A tracking algorithm corrected errors due to respiration, where 4 independent observers compared 25 respiration sequences to an automated method. Following correction of these errors, target registration error was assessed. At 20 mm and 30 mm from the phantom model\’s center point with an in-plane rotation of 8 degrees, measured error was 2.94 mm and 5.60 mm, respectively, and the main error identified. A priori method accurately predicted ECG location in only 38% (p=0.0003) of 313 R-R intervals in AF. A posteriori method accurately gated the ECG during AF and sinus rhythm in 97% and 98% of 375 beats evaluated, respectively (p=NS). Tracking algorithm for ECG-gated motion compensation was identified as good or fair 96% of the time, with no difference between observers and automated method (chi-square=25; p=NS). Target registration error in phantom and animal models was 1.75±1.03 mm and 0 to 0.5 mm, respectively.

Conclusions: Errors during cardiac image registration can be identified and corrected. Cardiac image stabilization can be achieved using ECG gating and respiration.

Anticoagulation after Atrial Fibrillation Ablation: Many Blanks to Fill

2011-01-03T01:59:00.000-08:00

Citation : Martin Fiala.Anticoagulation after Atrial Fibrillation Ablation: Many Blanks to Fill .JAFIB.2010 December;Volume 2 Issue(3): 853-855.

Long-term maintenance of sinus rhythm (SR) after catheter ablation of atrial fibrillation (AF) has remained an open issue awaiting further relevant data. It is of paramount importance as our everyday decisions on discontinuing anticoagulation after ablation rest on the belief in the absence of clinically significant asymptomatic AF episodes and constant SR for the rest of the patient\'s life. Both aspects are difficult to ascertain, for the tools of truly continuous ECG monitoring are not comfortably applicable, and routine follow-up tends to thin out beyond 1 year in asymptomatic patients without apparent arrhythmia recurrences.

Atrial Tachycardia Successfully Ablated from the Left Coronary Sinus Cusp of the Aorta: An Unusual Site of Origin

2011-01-03T01:57:00.000-08:00

Citation : Takumi Yamada.Atrial Tachycardia Successfully Ablated from the Left Coronary Sinus Cusp of the Aorta: An Unusual Site of Origin .JAFIB.2010 December;Volume 2 Issue(3): 851-852.

It has been recognized in the last decade that atrial and ventricular tachycardias may arise from the myocardium around the aorta. These tachycardias can be ablated from the coronary sinus cusps of the aorta (ASCs). In some of those tachycardias, the site of origin may be epicardial and thus can be ablated only through the thin structure of the ASCs. It is important to know how to make a diagnosis, map and ablate tachycardias arising from this region.

The Use of Cryoballoon Ablation in Atrial Fibrillation: Simplifying Pulmonary Vein Isolation?

2011-01-03T01:55:00.001-08:00

Citation : Gian Battista Chierchia, Antonio Sorgente, Andrea Sarkozy, Carlo de Asmundis, Pedro Brugada.The Use of Cryoballoon Ablation in Atrial Fibrillation: Simplifying Pulmonary Vein Isolation? .JAFIB.2010 December;Volume 2 Issue(3): 839-850.

Atrial fibrillation (AF) is certainly the most common arrhythmia encountered in clinical practice, reaching epidemic proportions in occidental society. Nowadays, transcatheter ablation using radiofrequency (RF) has become a popular technique in the treatment of drug-resistant AF. Since ectopic beats originating from the pulmonary veins (PVs) have been shown to be the main trigger initiating AF, electrical isolation of these venous structures has become the goal when performing this procedure.

Atrial Fibrillation after Cardiac Surgery: Benign or Deserving of Prophylaxis

2011-01-03T01:51:00.001-08:00

Citation : Stephen Westaby.Atrial Fibrillation after Cardiac Surgery: Benign or Deserving of Prophylaxis .JAFIB.2010 December;Volume 2 Issue(3): 835-838.

New onset atrial fibrillation (AF) is the commonest complication after cardiac surgery affecting around 30% of coronary artery bypass graft (CABG) patients, up to 50% of valve surgery patients and as many as 60% of those undergoing combined valve and CABG operations.

Gender and Racial Characteristics of Patients Referred to a Tertiary Atrial Fibrillation Center

2011-01-03T01:49:00.001-08:00

Citation : Pamela K. Mason, Liza Moorman, Douglas E. Lake, J. Michael Mangrum, John P. DiMarco, John D. Ferguson, Srijoy Mahapatra, Kenneth C. Bilchick, David Wiggins, J. Paul Mounsey, J. Randall Moorman.Gender and Racial Characteristics of Patients Referred to a Tertiary Atrial Fibrillation Center .JAFIB.2010 December;Volume 2 Issue(3): 827-834.

Atrial Fibrillation Centers (AFCs) are becoming increasingly common and are often developed at institutions to provide comprehensive evaluation and management for patients with atrial fibrillation (AF) including catheter and surgical ablation. Studies have shown that women and racial minority patients are less likely to be offered aggressive or invasive therapies. The University of Virginia (UVA) AFC was opened in 2004. We analyzed data collected during initial visits to our AFC from 2004-2008 to determine the gender and racial characteristics of a tertiary AFC population. Multivariable regression analysis was used to compare clinical characteristics. There were a total of 1664 consecutive initial patient visits. Cardiologists referred 61% and primary care physicians referred 37% of patients. Twice as many men were referred as women (570 vs. 1094; P< 0.0001). Women were older (68.0+11.9 vs. 62.4+13.0 years; P< 0.0001) and more symptomatic with palpitations (80% vs. 73%; P=0.008), but otherwise were not substantially different from men. Both men and women were aggressively treated with anticoagulation and rate-controlling medications by our referring physicians. Minority patients were infrequently referred, with only 46 African American patients in the total population. In conclusion, the demographics of a tertiary FAC are different than those of the general population. Women and racial minority patients are underrepresented, and the women have few comorbidities and symptoms than the known epidemiology would lead us to expect.

Reducing Ionizing Radiation Associated with Atrial Fibrillation Ablation

2011-01-03T01:47:00.000-08:00

Citation : Nisha L. Bhatia, Arshad Jahangir, William Pavlicek, Luis R.P. Scott, Gregory T. Altemose, Komandoor Srivathsan.Reducing Ionizing Radiation Associated with Atrial Fibrillation Ablation .JAFIB.2010 December;Volume 2 Issue(3): 822-826.

While radiation exposure with cardiac interventional procedures is an emerging concern, patients undergoing radiofrequency ablation (RFA) for atrial fibrillation (AF) still routinely undergo pre- and post-ablation computed tomography (CT) scans for 1) definition of left atrial and pulmonary vein anatomy, 2) creation of a surrogate geometry, and 3) assessment for complications such as pulmonary vein (PV) stenosis. In an effort to decrease ionizing radiation associated with atrial fibrillation ablation, an ultrasound-guided surrogate geometry approach is proposed as an alternative to routine CT imaging. Ten patients underwent AF ablation using intracardiac ultrasound for the creation of a surrogate left atrial geometry (CartoSound, Biosense Webster, CA); and ten control-cases who had conventional CT-guided imaging (CartoMerge, Biosense Webster, CA) were matched for age, gender, and type of catheter ablation. Sources of radiation included 1) intraprocedural fluoroscopy (CartoSound: 151 ± 43 mGray*cm^2, CartoMerge: 174 ± 130 mGray*cm^2; p=0.6) and 2) CT ionizing radiation (CartoSound: 0 mSv, CartoMerge 9.4 ± 2.3 mSv/CT scan.) When comparing clinical success rates after a trial of previously ineffective anti-arrhythmic drugs, ultrasound-guided AF ablation was non-inferior to a CT-guided approach, and obviated the need for CT imaging, therefore reducing doses of ionizing radiation by nearly 20 mSv per AF catheter ablation.

Left Atrial Volume and Post-Operative Atrial Fibrillation after Aortic Valve Replacement

2011-01-03T01:44:00.001-08:00

Citation : Yeruva Madhu Reddy, Ruby Satpathy, Xuedong Shen, Mark Holmberg, Claire Hunter, Aryan Mooss, Dennis Esterbrooks.Left Atrial Volume and Post-Operative Atrial Fibrillation after Aortic Valve Replacement .JAFIB.2010 December;Volume 2 Issue(3): 814-821.

Post-operative atrial fibrillation (POAF) after valve surgery is associated with increased morbidity and mortality. Risk factors identified in the past to predict POAF are of moderate accuracy. We performed a retrospective analysis of 139 patients undergoing aortic valve replacement for aortic stenosis. Post-operative AF occurred in 44% of the patients. In multivariate analysis only left atrial volume (LAV) index was a predictor of POAF. A LAV index of >46 cc/m2 predicted POAF with a sensitivity and specificity of 92% and 77%. We propose that LAV index can be used preoperatively to identify patients at risk for POAF to target preventive interventions.

The Power of One: a Highly Detailed, Log-Based, Case Example that Clearly Demonstrates the Effective Use of Ranolazine for the Control of Progressive

2010-10-31T23:49:00.001-07:00

Citation : James A. Reiffel.The Power of One: a Highly Detailed, Log-Based, Case Example that Clearly Demonstrates the Effective Use of Ranolazine for the Control of Progressive Atrial Fibrillation. .JAFIB.2010 October;Volume 2 Issue(2): 810-813.

This manuscript is a case report documented by a detailed patient log, that demonstrates efficacy of ranolazine for the management of paroxysmal atrial fibrillation that was progressive and resistant to prior antiarrhythmic drug therapy.

Ablation of Longstanding Persistent Atrial Fibrillation

2010-10-31T23:45:00.000-07:00

Citation : Edward J. Ciaccio.Ablation of Longstanding Persistent Atrial Fibrillation .JAFIB.2010 October;Volume 2 Issue(2): 806-809.

To prevent recurrence of paroxysmal atrial fibrillation (AF, events < 7 days) isolation of pulmonary vein (PV) triggers results in success rates of up to 0.9 (i.e. 90%). Recent evidence suggests that complete circumferential antral ablation is not even necessary for PV isolation. When AF persists beyond one week, electrical and anatomic substrate remodeling typically occurs. Initially, when remodeling is slight, the arrhythmia can be terminated by PV isolation with only a few left atrial ablation lesions required in addition. However if longstanding persistent atrial fibrillation is present (defined as event duration > 6 months4 or > 1 year) greater left atrial substrate modification is necessary

Commentary on: Pericardial Fat is Independently Associated with Human Atrial Fibrillation by Al Chekakie et al.

2010-10-31T23:42:00.000-07:00

Citation : Omar Batal,Mina K. Chung.Commentary on: Pericardial Fat is Independently Associated with Human Atrial Fibrillation by Al Chekakie et al. .JAFIB.2010 October;Volume 2 Issue(2): 803-805.

Obesity is an established risk factor for atrial fibrillation (AF). In fact, it has been reported that the increasing prevalence of obesity in the United States could account for up to 60 % of the increasing incidence of age and sex adjusted AF. Adipose tissue has been shown to be highly metabolically active and secretes several proinflammatory mediators; however, different fat depots differ in metabolic and inflammatory activity.

Left Atrial Appendage: Extending the Search for New Sources of Atrial Fibrillation Triggers

2010-10-31T23:40:00.000-07:00

Citation : Yoshihide Takahashi.Left Atrial Appendage: Extending the Search for New Sources of Atrial Fibrillation Triggers .JAFIB.2010 October;Volume 2 Issue(2): 802.

The discovery of the role of the pulmonary veins (PVs) in atrial fibrillation (AF) has facilitated us to perform an anatomy-based ablation, “PV isolation”. Although several new mapping technologies have been developed, activation mapping during ongoing AF is still challenging. To improve the efficacy of AF ablation, therefore, we attempted to find the second “hot spot”. The superior vena cava, ligament of Marshall, coronary sinus and posterior LA have been reported as second critical areas for AF ablation. However, there remain patients who are refractory to catheter ablation targeting all of those above areas.

Stroke Prevention in Atrial Fibrillation

2010-10-31T23:38:00.000-07:00

Citation : Tatjana Rundek, Sebastian Koch, Michael Katsnelson.Stroke Prevention in Atrial Fibrillation .JAFIB.2010 October;Volume 2 Issue(2): 790-801.

Non-valvular atrial fibrillation has been shown to be the most common cardiac arrhythmia with a growing world-wide incidence and a profound, better understood associated morbidity and mortality, most notably with cardioembolic strokes. This brief review highlights the risk of stroke and important studies of the latest treatment modalities available for stroke prevention in patients with non-valvular atrial fibrillation.

Management of Atrial Fibrillation in Pregnancy

2010-10-31T23:30:00.000-07:00

Citation : Luca Cacciotti, Ilaria Passaseo.Management of Atrial Fibrillation in Pregnancy .JAFIB.2010 October;Volume 2 Issue(2): 785-789.

Pregnancy is accompanied by a variety of cardiovascular changes in normal women; all of these changes are thought to promote arrhythmogenesis. Atrial fibrillation is unusual during pregnancy and it can represent a benign, self-limited lone atrial fibrillation or can be hemodynamically significant in parturient with or without structural heart disease. Management of atrial fibrillation should be the same as in non-pregnant women, but requires faster intervention, even in patients with a normal heart function, and cautious use of medication to avoid harm to the fetus. We might remember that synchronized electrical cardioversion has been performed safely during all stages of pregnancy.

Atrial Tachycardias Occurring After Atrial Fibrillation Ablation: Strategies for Mapping and Ablation

2010-10-31T23:27:00.000-07:00

Citation :
Stavros Mountantonakis, Edward P.Gerstenfeld.Atrial Tachycardias Occurring After Atrial Fibrillation Ablation: Strategies for Mapping and Ablation .JAFIB.2010 October;Volume 2 Issue(2): 770-784.

The occurrence of left atrial tachycardias (AT) after catheter ablation for atrial fibrillation (AF) are common, especially after more extensive ablation of persistent AF. These AT are invariably symptomatic and often do not respond to medical therapy. The initial strategy involves ventricular rate control, cardioversion, and observation as some tachycardias may resolve with time. For persistent ATs, effective management frequently requires catheter intervention. Careful characterization of the tachycardia mechanism is essential in designing an effective ablation strategy that would also avoid further creation of pro-arrhythmic substrate. With this review, we summarize the incidence, mechanism, diagnosis and treatment of ATs occurring after AF ablation.

Endurance Sport Practice and Atrial Fibrillation

2010-10-31T23:21:00.000-07:00

Citation : Lluis Mont, Naiara Calvo.Endurance Sport Practice and Atrial Fibrillation .JAFIB.2010 October;Volume 2 Issue(2): 762-769.

Atrial fibrillation (AF) is the most common cardiac rhythm disorder in clinical practice, with an estimated prevalence of 0.4% to 1% in the general population, increasing with age to 8% in those older than 80 years. The recognized risk factors for developing AF include age, hypertension, structural heart disease, diabetes mellitus, and hyperthyroidism. However, the etiology remains unclear in a significant number of patients younger than age 60 in whom no cardiovascular disease or any other known causal factor is present. This condition is termed lone AF, and may be responsible for as many as 30% of patients with paroxysmal AF seeking medical attention. Although regular physical activity clearly reduces cardiovascular morbidity risk, in recent years long-term endurance sport practice has been recognized as a risk factor for AF. However, the underlying mechanism explaining this association is unclear.

Angiotensin Receptor Blockers for the Prevention of Atrial Fibrillation Recurrences: Unending Hot Debate

2010-10-31T23:12:00.000-07:00

Citation : Turgay Celik.Angiotensin Receptor Blockers for the Prevention of Atrial Fibrillation Recurrences: Unending Hot Debate .JAFIB.2010 October;Volume 2 Issue(2): 760-761.

Although there is a plausible scientific basis for the notion that inhibition of the renin-angiotensin system can reduce the incidence of atrial fibrillation (AF) the greatest benefit was seen in patients with heart failure/left ventricular dysfunction in whom therapy with an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blockers (ARBs) is probably already indicated. A number of initial studies suggested that ACE inhibitors and ARBs might prevent new onset and recurrent AF. However, the available data do not support the use of these drugs solely for the prevention of AF. I believe that additional prospective definitive trials are needed to clarify the role of ARBs in the prevention of AF recurrence.

Effect of High-dose Telmisartan on the Prevention of Recurrent Atrial Fibrillation in Hypertensive Patients

2010-10-31T22:46:00.000-07:00

Citation : Shingo Maeda, Mitsuhiro Nishizaki, Noriyoshi Yamawake, Takashi Ashikaga, Kensuke Ihara, Tadashi Murai, Hiroyuki Fujii, Harumizu Sakurada, Masayasu Hiraoka, Mitsuaki Isobe.Effect of High-dose Telmisartan on the Prevention of Recurrent Atrial Fibrillation in Hypertensive Patients .JAFIB.2010 October;Volume 2 Issue(2): 747-759.

Background: Telmisartan has been shown to exert an equivalent action as ramipril on the prevention of cardiovascular events, but the dose-dependent actions of telmisartan on the prevention of events remain unknown.

Objective: We investigated the dose-dependent effects of telmisartan on the prevention of AF in patients associated with risk factors.

Methods: One hundred hypertensive patients were randomized to take 40 mg (low-dose group: n=57) or 80 mg (high-dose group: n=43) of telmisartan for 24 months. The primary endpoints were defined as a new development and/or recurrence of atrial fibrillation (AF).

Results: The mean values of the blood pressure in both groups decreased significantly and to similar degrees after 24 months, in the low-dose (p < 0.01) and high-dose (p < 0.01) groups. At the end of the follow-up, the incidence of AF was lower in the high-dose group than in the low-dose group (p < 0.05). Moreover, the proportion of AF recurrences in the patients with a past history of paroxysmal AF was lower in the high-dose group than in the low-dose group (p < 0.05). Further, using a logistic regression model, there were no risk factors associated with the incidence of AF.

Conclusion: The results indicated that telmisartan in low doses was as effective in controlling the blood pressure as in high doses, but high doses of telmisartan had beneficial effects on preventing the recurrence of AF in hypertensive patients.

Use of Ivabradine in Postural Orthostatic Tachycardia Syndrome

2010-09-02T06:23:00.000-07:00

Citation : Jamil-Copley S, Nagarajan DV, Baig MK.Use of Ivabradine in Postural Orthostatic Tachycardia Syndrome .JAFIB.2010 May;Volume 2 Issue(1): 745-746.

Postural orthostatic tachycardia syndrome (POTS) is characterized by inappropriate increase in heart rate on assuming upright position from a supine position without a necessary drop in blood pressure. Etiology of this condition is complex and multifactorial. Autonomic dysfunction, hypovolemia, hyper responsiveness of beta adrenergic receptors with associated elevations of plasma norepinephrine levels have been implicated as underlying pathophysiologic mechanisms. Beta blockers have previously been used to treat this condition. Ivabradine which selectively inhibits If ion current in the sino atrial node, has been reported to be useful in patients with POTS. We present one further such case of POTS successfully treated by Ivabradine.

Supraventricular Ectopic Activity: When Excessive it is not all Benign!

2010-09-02T06:21:00.000-07:00

Citation : Tuan Le Nguyen, Liza Thomas.Supraventricular Ectopic Activity: When Excessive it is not all Benign! .JAFIB.2010 May;Volume 2 Issue(1): 742-744.

Stroke is a significant cause of mortality and disabling morbidity. The major subtypes of stroke are divided into thrombo-embolic, haemorrhagic and cryptogenic, with each having different predisposing risk factors and management strategies. Atrial fibrillation (AF) is the commonest arrhythmia predisposing to thrombo-embolic stroke. The incidence of AF increases with age, affecting up to 5% in the elderly population. Electrophysiology studies have implicated that spontaneous atrial ectopic beats that originate in or near pulmonary veins adjacent to the left atrium, may initiate paroxysms of AF.

Commentary on : New-Onset Atrial Fibrillation Predicts Long-Term Mortality After Coronary Artery Bypass Graft by El-chami et.al

2010-09-02T06:20:00.000-07:00

Citation : Giovanni Filardo.Commentary on : New-Onset Atrial Fibrillation Predicts Long-Term Mortality After Coronary Artery Bypass Graft by El-chami et.al .JAFIB.2010 May;Volume 2 Issue(1): 740-741.

El-Chami and colleagues report that new-onset post-operative atrial fibrillation (AF) is associated with a significant reduction in long-term survival (adjusted hazard ratio: 1.21; 95% confidence interval: 1.12 to 1.32; follow-up: mean 6 years, range: 0 to 12.5 years) for patients undergoing isolated coronary artery bypass grafting (CABG). Moreover, the authors suggest that patients with new-onset post-CABG AF discharged on warfarin experienced reduced mortality during follow-up (adjusted HR: 0.78, 95% CI: 0.66 to 0.92) when compared to those who were not discharged on warfarin.

Is AF Ablation Cost Effective?

2010-09-02T06:18:00.000-07:00

Citation :
William Martin-Doyle, Matthew R. Reynolds.Is AF Ablation Cost Effective? .JAFIB.2010 May;Volume 2 Issue(1): 727-739.

The use of catheter ablation to treat AF is increasing rapidly, but there is presently an incomplete understanding of its cost-effectiveness. AF ablation procedures involve significant up-front expenditures, but multiple randomized trials have demonstrated that ablation is more effective than antiarrhythmic drugs at maintaining sinus rhythm in a second-line and possibly first-line rhythm control setting. Although truly long-term data are limited, ablation, as compared with antiarrrhythmic drugs, also appears associated with improved symptoms and quality of life and a reduction in downstream hospitalization and other health care resource utilization. Several groups have developed cost effectiveness models comparing AF ablation primarily to antiarrhythmic drugs and the model results suggest that ablation likely falls within the range generally accepted as cost-effective in developed nations. This paper will review available information on the cost-effectiveness of catheter ablation for the treatment of atrial fibrillation, and discuss continued areas of uncertainty where further research is required.

Invasive Management of Atrial Fibrillation and the Elderly

2010-09-02T06:17:00.000-07:00

Citation : Sandeep M. Patel, Samuel J. Asirvatham.Invasive Management of Atrial Fibrillation and the Elderly .JAFIB.2010 May;Volume 2 Issue(1): 715-726

Atrial fibrillation (AF) is the most common arrhythmia encountered by caregivers for the elderly. A plethora of new, mostly invasive techniques have evolved to treat patients who remain symptomatic from this arrhythmia despite attempts at pharmacological therapy. The most widely-used of these new techniques is radiofrequency ablation, but in select patients, special types of pacemaker, cryoablation, and surgical maze therapy may be of benefit.

Ranolazine for Atrial Fibrillation: Too Good to be True?

2010-09-02T06:13:00.000-07:00

Citation : Joseph J. Gard, Samuel J. Asirvatham. Ranolazine for Atrial Fibrillation: Too Good to be True? .JAFIB.2010 May;Volume 2 Issue(1): 711-714.

Several management options for patients with symptomatic atrial fibrillation (AF) available today were not even in the realm of discussion two decades ago. These advances, however, have primarily involved invasive management options for patients with drug refractory arrhythmia. After the recognition that electrical isolation of the thoracic veins benefits patients with paroxysmal AF, a slew of more involved ablative techniques evolved. Major breakthroughs in antiarrhythmic therapy, however, have not paralleled this meteoric development of invasive techniques. The drive for invasive procedures has, in fact, been widely based on the lack of availability of simple, effective, and safe pharmacological options for AF. The introduction of dronedarone into clinical practice represented a recent addition to antiarrhythmic therapy options for use in the management of patients with AF. This agent is an analogue of amiodarone but devoid of the iodine moiety which allows its use without the well-recognized and dreaded organ toxicity associated with long-term use. Nevertheless, a significant need exists for a drug with limited side effects that can be used for symptomatic intermittent AF without the need for daily chronic use, fear of organ toxicity, and concern regarding proarrhythmia in patients with structural heart disease.

The Conversion of Paroxysmal or Initial Onset Atrial Fibrillation with Oral Ranolazine: Implications for a New "Pill-In-Pocket" Approach in Structural

2010-09-02T06:11:00.000-07:00

Citation : David K. Murdock, James A Reiffel, Jeff Kaliebe, German Larrain.The Conversion of Paroxysmal or Initial Onset Atrial Fibrillation with Oral Ranolazine: Implications for a New "Pill-In-Pocket" Approach in Structural Heart Disease .JAFIB.2010 May;Volume 2 Issue(1): 705-710.

Background: The "Pill-in-Pocket" (PIP) is an approach to atrial fibrillation (AF) where oral anti-arrhythmics at 75% to 100% of the normal daily dose, given as a single dose, is used to convert recent-onset AF. Pro-arrhythmic risk has limited this approach to patients without structural heart disease (SHD). Ranolazine is an anti-anginal agent, which inhibits the abnormal late Na+ channel current resulting in decreased Na+/Ca++ overload. This inhibits after-depolarizations and reduces pulmonary vein firing, which have been implicated in the initiation and propagation of AF. Ranolazine increases atrial refractoriness and has no known pro-arrhythmic affects. Ranolazine is routinely given to patients with SHD. The ability of Ranolazine to terminate AF in man has not been described but if useful could be a safer PIP agent with application in the presence or absence of SHD. We describe our experience using oral Ranolazine to convert new or recurrent AF.
Method: 2000 mg of ranolazine was administered to 35 patients with new (16 patients) or recurrent (19 patients) AF of at least 3 but not greater than 48 hours duration. Clinical features, echocardiographic data, and SHD were noted. Success was defined as restoring sinus rhythm within 6 hours of Ranolazine.
Results: All but 4 patients had some form of SHD. Twenty-five patients were in the hospital, 5 were in the office, and 5 were at home at the time Ranolazine was administered. Twenty-five of 35 patients converted to sinus rhythm. No pro-arrhythmic effects, hemodynamic instability, adverse rate effects, or perceived intolerance were noted. The 71% conversion rate was comparable to other reported PIP protocols and much higher than reported placebo conversion rates.
Conclusion: High dose oral Ranolazine shows utility as a possible safe agent to convert new or recurrent AF. Larger placebo-controlled studies would appear to be warranted.

AF Termination: the Holy Grail of Persistent AF Ablation?

2010-09-02T06:08:00.000-07:00

Citation : Dennis H. Lau, Anthony G. Brooks, Prashanthan Sanders.AF Termination: the Holy Grail of Persistent AF Ablation? .JAFIB.2010 May;Volume 1 Issue(12): 702-704.

The optimal catheter ablation approach for long-standing persistent atrial fibrillation (AF) remains elusive despite significant advances made in our understanding of this arrhythmia. A recent systematic review highlighted the significant variation in procedural success rate both within and between techniques, necessitating repeat ablation procedures and anti-arrhythmic drugs to achieve improved outcomes in those with long-standing persistent AF. Indeed, current expert consensus statement recommended ablation beyond ostial pulmonary vein isolation for these patients.

Atrial Fibrillation Susceptibility Alleles on Chromosome 4q25 Modulate Response to Catheter Ablation

2010-09-02T06:07:00.000-07:00

Citation : Dawood Darbar.Atrial Fibrillation Susceptibility Alleles on Chromosome 4q25 Modulate Response to Catheter Ablation .JAFIB.2010 May;Volume 1 Issue(12): 699-701

In the last five years, increasing evidence has emerged for a genetic predisposition to atrial fibrillation (AF). Framingham Heart Study investigators observed that the odds of developing AF were three times higher for individuals with at least one parent in whom AF was diagnosed before the age of 75 than in those without a parental history of AF. Similarly, in a large group of Icelanders, the risk of developing AF was increased nearly five-fold if one parent was affected before the age of 60. Furthermore, single rare genetic variants thought to be responsible for familial AF have been identified.

Is Isolation of Arrhythmogenic Pulmonary Veins Sufficient for the Long-term Efficacy of Atrial Fibrillation Ablation?

2010-09-02T06:05:00.000-07:00

Citation :Sanjay Dixit. Is Isolation of Arrhythmogenic Pulmonary Veins Sufficient for the Long-term Efficacy of Atrial Fibrillation Ablation? .JAFIB.2010 May;Volume 1 Issue(12): 685-698.

Atrial fibrillation (AF) is the commonest cardiac rhythm disorder, affecting about 5% of elderly patients. Despite the wide spread prevalence of AF, treatment options for the condition up until recently, were limited. Antiarrhythmic drug therapy which for a long time had been and to some extent still is the cornerstone for treating these patients, has shown a disappointing (£ 40%) efficacy for long-term maintenance of sinus rhythm. The seminal observations by Haissaguerre and colleagues demonstrating AF initiation from electrical depolarizations in the pulmonary veins (PV) and cure of AF in these patients by radiofrequency ablation (RFA) of the PV focus, has led to the emergence of percutaneous catheter based AF ablation. Since its original description in 1998, the AF ablation procedure has evolved considerably.

Lone AF – Etiologic Factors and Genetic Insights into Pathophysiolgy

2010-09-02T06:04:00.000-07:00

Citation : Babar Parvez, Dawood Darbar. Lone AF – Etiologic Factors and Genetic Insights into Pathophysiolgy .JAFIB.2010 May;Volume 1 Issue(12): 675-684.

Ever since atrial fibrillation (AF) was first recognized in young people (so called “lone” AF) over 4 decades ago, there has been increasing focus on determining the underlying pathophysiology of condition. Although lone AF is presumed to be a highly heterogeneous disease, recent studies have identified novel risk factors such as inflammation, oxidative stress, endurance sports and genetics, for the arrhythmia. This monograph aims to highlight some of the recent advances in our understanding of the molecular pathophysiology of lone AF especially insight provided by contemporary genetic studies. These insights may provide novel therapeutic targets for treatment of this challenging arrhythmia in young patients.

The Utility of Ambulatory Electrocardiographic Monitoring for Detecting Silent Arrhythmias and Clarifying Symptom Mechanism in an Elderly Urban Popula

2010-09-02T06:01:00.000-07:00

Citation : Kathleen T. Hickey, James Reiffel, Robert R. Sciacca, William Whang, Angelo Biviano, Maurita Baumeister, Carmen Castillo, Jyothi Talathothi, Hasan Garan.The Utility of Ambulatory Electrocardiographic Monitoring for Detecting Silent Arrhythmias and Clarifying Symptom Mechanism in an Elderly Urban Population with Heart Failure and Hypertension: Clinical Implications .JAFIB.2010 May;Volume 1 Issue(12): 663-674.

Background: Atrial and ventricular tachyarrhythmias, including atrial fibrillation (AF) as well as bradyarrhythmias have been well documented in elderly and generally symptomatic patients with heart failure (HF) and/or hypertension (HTN), most often using 24 hour continuous monitoring. However, the frequency of these arrhythmias, including silent as well as symptomatic, as assessed by more prolonged monitoring, the relationship between symptoms in patients with HF and/or HTN and an underlying arrhythmia, and the association of arrhythmias including those that are silent with subsequent cardiac events has not been well defined in patients 65 years or older with HF and other cardiovascular risk factors. Importantly in such patients, AF, even if symptomatic, would yield a CHADS2 score indicative of anticoagulation.

Objective: A pilot study to assess the potential value of 2 weeks of out-patient, transtelephonic cardiac auto-triggered loop-monitoring for detecting arrhythmias, assessing their relationship to symptoms, predicting the risk of subsequent cardiac events, and determining if they result in therapy in an elderly, urban population living with HF.

Methods: Fifty-four subjects with a history of systolic HF and/or HTN consented to wear an auto triggered cardiac loop monitor for 2 weeks. This device captures EKG data, including silent and symptomatic arrhythmias. Subjects were requested to transmit data once daily as well as to transmit if they were symptomatic to determine if an underlying dysrhythmia was present.

Results: Mean age was 73 ± 6 years with 59% were female, 74% Hispanic, 22% black, and 4% white/other. All subjects had HF and 94% had HTN; all were in sinus rhythm at the time of enrollment. From the cardiac monitoring, 72% demonstrated ectopic atrial and ventricular activity. In addition, 1 paroxysmal episode of AF was documented, 3 people had significant non-sustained ventricular tachycardia that contributed to the placement of an internal cardioverter defibrillator (ICD), and 4 individuals underwent subsequent placement of a pacemakers for severe bradycardia/heart block (per established guidelines). The relationship between arrhythmia and symptoms was weak. These events would have otherwise gone undetected and untreated. During follow-up, 15 subjects (28%) had significant cardiac events, including one patient with a non ST segment myocardial infarction (NSTEMI) infarct due to undetected and untreated AF and one patient with symptomatic 2:1 atrial flutter. The AF and flutter patients all had CHADS2 scores appropriate for initiation of anticoagulation.

Conclusion: A substantial proportion of subjects exhibited arrhythmias during monitoring, cardiac events during follow-up and consequent therapy. This approach to arrhythmia screening appears to have sufficient merit to warrant further study.

Electrophysiological Changes of the Atrium in Patients with Lone Paroxysmal Atrial Fibrillation

2010-09-02T05:31:00.001-07:00

Citation : Osmar Antonio Centurion, Shojiro Isomoto, Akihiko Shimizu.Electrophysiological Changes of the Atrium in Patients with Lone Paroxysmal Atrial Fibrillation .JAFIB.2010 May;Volume 1 Issue(12): 656-662.

Introduction: Paroxysmal atrial fibrillation (PAF) is a common arrhythmia, and it is associated with various cardiac conditions. On the other hand, lone PAF has no identifiable underlying cause, and can occur any time for no apparent reason. The underlying causes may modify the electrophysiological properties of the atrium in different ways and extent. However this setting may be different in patients with lone PAF. We sought to investigate the atrial electrophysiological properties in lone PAF.
Material and Methods: This study included 62 control subjects (Control group) and 58 patients with lone PAF (LAF group). The following atrial vulnerability parameters induced by programmed atrial stimulation were assessed and quantitatively measured: 1) the atrial effective refractory period (ERP), 2) the atrial conduction delay (CD) zone, and 3) the maximum CD.
Results: The mean atrial ERP of the Control group was 215±29 ms, and that of LAF group was 208±28 ms, p<0.05. The mean atrial CD zone of the LAF group was (50±28 ms) significantly greater than that of controls (34±22 ms) (p<0.01). The mean maximum CD of the LAF group (62±29 ms) was also significantly greater than that of controls (43±20 ms) (p<0.01).
Conclusions: There is a greater conduction delay of the atrium and shorter refractoriness in patients with lone PAF. Patients without underlying causes for the development of PAF exhibit abnormalities in the electrophysiological properties of the atrium.
Key words: Atrial vulnerability. Atrial refractory period. Atrial conduction time. Atrial fibrillation. Atrial conduction delay.

Determining esophageal anatomy with a new electroanatomical mapping system Short Title – Esophageal anatomy during PVI Diego Chemello MD, Imad Ham

2010-04-10T05:44:00.000-07:00

Citation : Diego Chemello, Imad Hameedullah, Anandaraja Subramanian, Eugene Downar.Determining esophageal anatomy with a new electroanatomical mapping system .JAFIB.2010 March;Volume 1 Issue(11): 653-655.

A 53-year-old woman with symptomatic paroxysmal atrial fibrillation was referred for pulmonary vein isolation (PVI). After obtaining access to left atrium (LA) and placement of catheters by standard technique, a high-resolution electroanatomical map of the LA and the pulmonary veins (PVs) was constructed using a map catheter (EZ Steer® Bi-directional catheter, Biosense Webster, Inc. Diamond Bar, USA) and the Carto® 3 System (Biosense-Webster Inc. Diamond Bar, USA) in the Fast Anatomical Mapping (FAM) mode.

An Update on the Energy Sources and Catheter Technology for the Ablation of Atrial Fibrillation

2010-04-10T05:42:00.000-07:00

Citation : Pawan K. Arora, James C. Hansen, Adam D. Price, Josef Koblish, Boaz Avitall.An Update on the Energy Sources and Catheter Technology for the Ablation of Atrial Fibrillation .JAFIB.2010 March;Volume 1 Issue(11): 632-652.

The ablation of atrial fibrillation (AF) is an area of intense research in cardiac electrophysiology. In this review, we discuss the development of catheter-based interventions for AF ablation. We outline the pathophysiologic and anatomic bases for ablative lesion sets and the evolution of various catheter designs for the delivery of radiofrequency (RF), cryothermal, and other ablative energy sources. The strengths and weaknesses of various specialized RF catheters and alternative energy systems are delineated, with respect to efficacy and patient safety.

Atrial Fibrillation in Athletes - The Story Behind The Running Hearts

2010-04-10T05:30:00.000-07:00

Citation : Shaolong Li, Zhihui Zhang, Benjamin J. Scherlag, Sunny S. Po.Atrial Fibrillation in Athletes - The Story Behind The Running Hearts .JAFIB.2010 March;Volume 1 Issue(11): 626-631.

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice but the mechanisms underlying the initiation and maintenance of AF are yet to be clarified. It is well-known that regular exercise is beneficial to health and reduces the risks of cardiovascular diseases. However, recent studies suggest that long-term endurance exercise, including running [1], swimming, rowing [2] and cycling [3], or vigorous competitive sports may increase the incidence of AF in these athletes. This review article is intended to provide a summary of the possible links between exercise and AF.

Current Perspectives: Rheumatic Atrial Fibrillation

2010-04-10T05:26:00.000-07:00

Citation :Bhima shankar P.R, Hygriv Roa B, Jaishankar S, Narasimhan C.Current Perspectives: Rheumatic Atrial Fibrillation .JAFIB.2010 March;Volume 1 Issue(11): 616-625.

AF is a common arrhythmia associated with large burden of morbidity and mortality. In areas with a high prevalence of rheumatic heart disease, valve disease is the most common substrate for the occurrence of AF and this problem assumes greater importance because the resulting escalation in morbidity and mortality involves relatively younger population. As is true of the general population, the prevalence of AF in patients with rheumatic mitral valve disease (RMVD) increases with advancing age.

Effect of Statins in Preventing Postoperative Atrial Fibrillation Following Cardiac Surgery

2010-04-10T05:16:00.000-07:00

Citation : Liang Yin, Zhinong Wang, Yifeng Wang, Guangyu Ji, Zhiyun Xu.Effect of Statins in Preventing Postoperative Atrial Fibrillation Following Cardiac Surgery .JAFIB.2010 March;Volume 1 Issue(11): 609-615.

Background Postoperative occurrence of atrial ﬁbrillation (AF) has been associated with less favorable outcomes in patients undergoing cardiac surgery and may result in increased post-operative morbidity and mortality.

Objectives A systematic review and meta-analysis of published studies were conducted to verify the effect of statins in the occurrence of AF after cardiac surgery.

Methods Using the Medline database, the Cochrane clinical trials database and online clinical trial databases, we reviewed all randomized controlled trials (RCTs) and observational studies examining the risk factors of occurrence AF after CABG. We searched for literature published April 2009 or earlier.

Results Our review identified 6 studies (observational studies), involving 10165 patients, that examined the effect of statins on the occurrence of AF following cardiac surgery. Conflict from most of articles, the overall outcomes suggest that the statins group did not have a significant decrease in the occurrence of AF following cardiac surgery (P = 0.19).

Conclusions The preoperative medication of statins showed no significant decrease in AF occurrence following cardiac surgery in the Meta-analysis result. A more prospective studies and researches are needed to explore and demonstrate the real effect of statins on the postoperative AF.

Monomorphic Outflow Tract Ventricular Tachycardia: Unique Presenting Manifestation of Gitelman’s Syndrome

2010-01-11T05:34:00.000-08:00

Citation : Subba Reddy Vanga, Chandra Annapureddy, Mazda Biria, Dhanunjaya Lakkireddy.Monomorphic Outflow Tract Ventricular Tachycardia: Unique Presenting Manifestation of Gitelman’s Syndrome .JAFIB.2010 January;Volume 1 Issue(10): 606-608.

Outflow Tract Ventricular Tachycardia (OTVT) is typically seen in young to middle aged people with structurally normal hearts. These arrhythmias are triggered by emotional or stress factors and that responds to medications. Electrolyte abnormalities rarely cause ventricular arrhythmia. Gitelman’s syndrome, a rare autosomal recessive renal disorder causes hypokalemia, metabolic alkalosis and hypomagnesaemia. This disorder is often benign with mild clinical symptoms and excellent long-term prognosis. We present a case of Gitelman’s syndrome with symptomatic OTVT as initial manifestation.

Dabigatran, a direct thrombin inhibitor, in atrial fibrillation: Is it already time for a change in oral anticoagulation therapy?

2010-01-11T05:30:00.000-08:00

Citation : Osmar Antonio Centurion.Dabigatran, a Direct Thrombin Inhibitor, in Atrial Fibrillation: Is it Already Time for a Change in Oral Anticoagulation Therapy? .JAFIB.2010 January;Volume 1 Issue(10): 601-605.

Atrial fibrillation (AF) is a common arrhythmia, and its prevalence increases with aging and the severity of heart disease. AF affects more than 2 million people in the US, and more than 4 million in Europe. It is expected that the age adjusted prevalence in US will excede 10 million people by the year 2050 . In the last decade, we were able to see the light shed by several trials that dealt with AF mechanisms and the appropriate management of AF patients. Clinical studies have focused mainly on the electrophysiological properties of the substrate in the atrial muscle during sinus rhythm and on the atrial electrical responses elicited by premature stimulation method . However, many fundamental aspects of this arrhythmia have been poorly understood until quite recently, and there are several features on the mechanisms of AF that makes it difficult to manage it properly. Increasing awareness of AF as a disease with possible fatal complications rather than as an acceptable alternative to sinus rhythm has led to search for clear arguments to support a certain strategy as a gold standard.

The State of the Art in Pulmonary Vein Stenosis - Diagnosis & Treatment

2010-01-11T05:27:00.000-08:00

Citation : Lourdes R. Prieto.The State of the Art in Pulmonary Vein Stenosis - Diagnosis & Treatment .JAFIB.2010 January;Volume 1 Issue(10): 588-600.

Pulmonary vein stenosis is a rare but serious complication of pulmonary vein isolation to treat atrial fibrillation. Pulmonary vein angioplasty/stenting has emerged as the treatment of choice for significantly stenotic veins. Guidelines for post ablation evaluation of the pulmonary veins, including the timing and method of surveillance for possible stenosis, the criteria for intervention, the technical aspects of intervention, and finally the surveillance post intervention, are still being developed. The relatively high rate of restenosis after intervention in a subset of patients remains a great challenge. A better understanding of the pathophysiology underlying this syndrome is needed to appropriately answer many of the remaining questions. The goal of this manuscript is to describe what has been learned about this complication and its treatment from a relatively large experience in a single institution over the past decade, and provide a comprehensive review of the existing literature in order to shed as much light on the subject as is possible, while at the same time exposing the areas that need further study.

Management of the Asymptomatic Patient After Catheter Ablation of Atrial Fibrillation

2010-01-11T05:20:00.000-08:00

Citation : David S. Frankel, Edward P. Gerstenfeld.Management of the Asymptomatic Patient After Catheter Ablation of Atrial Fibrillation .JAFIB.2010 January;Volume 1 Issue(10): 580-587.

Ablative therapy for atrial fibrillation is becoming more commonplace, and some minimally symptomatic or asymptomatic patients will be referred for ablative therapy. Reasons to ablate asymptomatic patients include young age and/or the presence of a tachycardia induced cardiomyopathy; in addition, some symptomatic patients may become asymptomatic after ablation. Managing these patients can be challenging. In this review, we will discuss the use of telemetric monitoring, antiarrhythmic drugs and anticoagulation after ablation in asymptomatic patients with atrial fibrillation.

Abbreviations :
AAD - antiarrhythmic drugs
AF - atrial fibrillation
LVEF - left ventricular ejection fraction
TTM - transtelephonic monitor

C-Reactive Protein and the Risk of Atrial Fibrillation: A Systematic Review and Meta-Analysis

2010-01-11T05:14:00.000-08:00

Citation : Venkata M Alla, Senthil Thambidorai, Kishlay Anand, Aryan N Mooss, Richard Baltaro, Syed M Mohiuddin.C-Reactive Protein and the Risk of Atrial Fibrillation: A Systematic Review and Meta-Analysis .JAFIB.2010 January;Volume 1 Issue(10): 569-579.

There is increasing evidence linking C-reactive protein (CRP) and atrial fibrillation (AF). Despite the abundance of literature, confusion exists regarding this association because of inconsistent results. MEDLINE and Cochrane Controlled Trials Register databases were carefully searched through July, 2007 combining the following terms “C-reactive protein” and “atrial fibrillation”. Of the 106 studies initially identified, 7 studies with 7349 subjects (638 with AF) were included in the meta-analysis. Analysis yielded a relative risk of 1.51 (1.24, 1.84) for occurrence of AF when CRP level was above a cut off of 3-3.5 mg/l. When 2 studies with data on a higher cut off of 4.5-5.0 mg/l were analyzed separately, the relative risk was 4.03 (2.6, 6.2). Our study suggests that elevated CRP increases the relative risk for AF. The risk appears incremental with higher CRP levels conferring proportionately increased risk. There is an urgent need for further large scale well designed studies.

Level of natriuretic peptide Determines outcome in atrial fibrillation

2010-01-11T05:09:00.000-08:00

Citation : Qi-xian Zeng, Ming-fen Wei, Wei Zhang, Yun Zhang, Jing-quan Zhong.Level of natriuretic peptide Determines outcome in atrial fibrillation .JAFIB.2010 January;Volume 1 Issue(10): 559-568.

Background : Natriuretic peptide (NP) is high in atrial fibrillation (AF)and may decrease after cardioversion to sinus rhythm and the levels of atrial NP (ANP) and brain NP (BNP) in different types of AF and whether ANP and BNP have predictive values for relapsed AF have not been determined.
Purpose: We aimed to examine the levels of ANP and BNP in AF to determine their roles in different types of AF, including a predictive value in relapsed AF.
Methods and Results : ANP and BNP were measured in 100 consecutive patients with AF and without heart dysfunction at baseline and in 20 controls. All patients had higher levels than controls (p<0.01). After cardioversion treatment with antiarrhythmic therapy, 40 patients failed to cardiover cardioversion successfully and still showed AF, whereas 60 patients were successful. ANP and BNP levels decreased significantly after cardioversion (163.55±54.27pg/ml vs. 200.20±55.63 pg/ml; 124.15±43.00 pg/ml vs. 161.99±48.04 , for ANP and BNP respectively, both p<0.0001). 18 of the 60 successfully cardioverted patients had AF recurred within 24 hours, who were then excluded from 500-day follow-up and the remaining 42 patients were enrolled. During 500-day follow-up period, AF relapsed in 16 patients. Comparing with the 42 patients, the 16 patients showed higher concentrations of ANP (187.72±32.79 pg/ml vs. 138.42±30.65 pg/ml, p<0.0001). Besides, both ANP and BNP were significantly higher in the relapsed patients than those remained SR during follow-up (153.38±29.6 pg/ml vs. 129.21±27.98 pg/ml for ANP, p=0.01 and 147.41±25.95 pg/ml vs. 121.87±20.53pg/ml for BNP, p=0.001). The area under the receiver-operating characteristic curve was 0.799 for BNP and 0.706 for ANP in predicting a relapse of AF. Using the BNP optimized cut-off level of 138 pg/ml, relapsed AF can be predicted with relatively acceptable accuracy.
Conclusions : ANP and BNP decrease significantly after cardioversion in patients with AF, and both can be useful predictors of relapsed AF.
Key Words: Atrial fibrillation; ardioversion; ANP; BNP; relapse of atrial fibrillation

Role of Inflammation in Early AF Recurrence after PV Isolation

2009-10-31T07:23:00.000-07:00

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

2009-10-31T07:20:00.001-07:00

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!

2009-10-31T07:20:00.000-07:00

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

2009-10-31T07:15:00.001-07:00

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

2009-10-31T07:15:00.000-07:00

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?

2009-10-31T07:08:00.000-07:00

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

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

2009-08-20T04:12:00.000-07:00

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?

2009-08-20T04:02:00.001-07:00

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”

2009-08-20T04:02:00.000-07:00

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?

2009-08-20T03:57:00.000-07:00

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

2009-08-20T03:53:00.000-07:00

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

2009-08-20T03:50:00.000-07:00

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

2009-08-20T03:40:00.000-07:00

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.

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

2009-06-18T03:57:00.000-07:00

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

2009-06-18T03:56:00.000-07:00

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

2009-06-18T03:54:00.000-07:00

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

2009-06-18T03:49:00.000-07:00

Citation : Osmar Antonio Centurión, 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

2009-06-18T03:46:00.000-07:00

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

2009-06-18T03:40:00.001-07:00

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.

EDC Administrator

2009-04-10T00:20:00.000-07:00

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
Good interpersonal and communication skills
Problem solving skills
Accurate worker with attention to relevant details
Ability to set and meet deadlines
Good organizational and time management skills
Experience:1 - 3 Years
Education:UG - Any Graduate - Any Specialization
PG - Any PG Course - Any Specialization
Location:Hyderabad / Secunderabad
Contact:Novartis Healthcare Pvt Ltd
Website:http://www.novartis.com

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

2009-04-09T04:40:00.000-07:00

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

2009-04-09T04:37:00.000-07:00

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

2009-04-09T04:35:00.000-07:00

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 ....

2009-04-09T04:31:00.000-07:00

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

2009-04-09T04:29:00.000-07:00

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

2009-04-09T04:26:00.000-07:00

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

2009-04-09T04:25:00.000-07:00

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?

2009-04-09T04:23:00.000-07:00

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

2009-04-09T04:15:00.000-07:00

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.

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

2009-02-04T02:53:00.000-08:00

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"

2009-02-04T02:51:00.000-08:00

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"

2009-02-04T02:48:00.000-08:00

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

2009-02-04T02:46:00.000-08:00

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

2009-02-04T02:44:00.000-08:00

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?

2009-02-04T02:41:00.000-08:00

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

2009-02-04T02:37:00.000-08:00

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

2009-02-04T02:32:00.000-08:00

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

2009-02-04T02:21:00.000-08:00

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

2009-02-04T01:57:00.000-08:00

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.

Background:

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.

Conclusions:

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.

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

2009-01-08T04:05:00.000-08:00

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.

Atrial Fibrillation: a Patient’s Guide to Understanding Drug Therapy

2008-12-11T02:18:00.000-08:00

Citation : Ragini Bhakta.Atrial Fibrillation: a Patient’s Guide to Understanding Drug Therapy .JAFIB.2008 Dec;Volume 1 Issue(4): 255-256.

Atrial Fibrillation (AF) as defined by the American Heart Association is an irregular heart beat (rhythm) where the small upper chambers of the heart (atria) beat ineffectively. The atria cannot pump all of the blood out of the chambers, resulting in pooling of the blood or clot formation. Unfortunately, if a part of the clot leaves the atria, it can become lodged in an artery in the brain resulting in an ischemic stroke.

The A That Did Not Fib: Two Roads Both Traveled By

2008-12-11T02:15:00.000-08:00

Citation : James C. Hansen,Abraham G. Kocheril.The A That Did Not Fib: Two Roads Both Traveled By .JAFIB.2008 Dec;Volume 1 Issue(4): 250-254.

Case: A 64-year-old woman presented with palpitations. Her 24-hour Holter monitor revealed runs of presumed atrial fibrillation (AF). The patient was referred for EP study and AF ablation.

EPS: At EPS, an anterograde A-H jump was noted. Spontaneous bursts of tachycardia were seen, consisting of sinus atrial beats with dual ventricular responses, each preceded by a His deflection. There was no atrial fibrillation during the study. Radiofrequency ablation of the slow AV node pathway was performed. There were no inducible tachycardias and no A-H jump following the ablation. The patient had no recurrence post-procedure.

Discussion: This case presents a rare example of simultaneous dual anterograde AV-nodal conduction. The conditions leading to this phenomenon include dual AVN pathways, markedly slowed conduction in the slow pathway, and lack of retrograde conduction up either pathway such that reentry was impossible. An irregular, narrow-complex tachycardia resulted, initially interpreted as AF. Slow-pathway ablation was curative.

The Anticoagulated Atrial Fibrillation Patient Who Requires “Curative” Therapy for Prostate Carcinoma: a Bleeding Conundrum

2008-12-11T02:11:00.000-08:00

Citation : James A.Reiffel.The Anticoagulated Atrial Fibrillation Patient Who Requires “Curative” Therapy for Prostate Carcinoma: a Bleeding Conundrum .JAFIB.2008 Dec;Volume 1 Issue(4): 248-249.

With the aging of the population, the incidence of both prostate carcinoma (PCa) and atrial fibrillation (AF) has increased. Options for “curative therapy” PCa now include surgery, external beam radiation (EBT), and radioactive seed implantation (RSI). The latter two approaches, especially EBT, can produce radiation proctitis (RP) with rectal bleeding (RB). This poses an issue for anticoagulating the elderly AF patient who develops PCa. The attached case report of a 77 year old male who was treated with a combination of RSI and “low dose” EBT followed by recurrent severe rectal bleeding demonstrates the significance of this problem. In the AF patient with a CHADS2 score of 2 or more, and hence an indication for chronic warfarin therapy, the therapy of subsequently detected PCa requires careful consideration of the risks associated with its therapeutic options.

Is Rhythm Control with Pulmonary Vein Isolation Superior to Rate Control with AV Nodal Ablation in Patients with Heart Failure?

2008-12-11T02:07:00.000-08:00

Citation : Dhanunjaya Lakkireddy.Is Rhythm Control with Pulmonary Vein Isolation Superior to Rate Control with AV Nodal Ablation in Patients with Heart Failure? .JAFIB.2008 Dec;Volume 1 Issue(4): 246-247.

BACKGROUND: Pulmonary-vein isolation is increasingly being used to treat atrial fibrillation in patients with heart failure. METHODS: In this prospective, multicenter clinical trial, we randomly assigned patients with symptomatic, drug-resistant atrial fibrillation, an ejection fraction of 40% or less, and New York Heart Association class II or III heart failure to undergo either pulmonary-vein isolation or atrioventricular-node ablation with biventricular pacing. All patients completed the Minnesota Living with Heart Failure questionnaire (scores range from 0 to 105, with a higher score indicating a worse quality of life) and underwent echocardiography and a 6-minute walk test (the composite primary end point). Over a 6-month period, patients were monitored for both symptomatic and asymptomatic episodes of atrial fibrillation. RESULTS: In all, 41 patients underwent pulmonary-vein isolation, and 40 underwent atrioventricular-node ablation with biventricular pacing; none were lost to follow-up at 6 months. The composite primary end point favored the group that underwent pulmonary-vein isolation, with an improved questionnaire score at 6 months (60, vs. 82 in the group that underwent atrioventricular-node ablation with biventricular pacing; P<0.001), a longer 6-minute-walk distance (340 m vs. 297 m, P<0.001), and a higher ejection fraction (35% vs. 28%, P<0.001). In the group that underwent pulmonary-vein isolation, 88% of patients receiving antiarrhythmic drugs and 71% of those not receiving such drugs were free of atrial fibrillation at 6 months. In the group that underwent pulmonary-vein isolation, pulmonary-vein stenosis developed in two patients, pericardial effusion in one, and pulmonary edema in another; in the group that underwent atrioventricular-node ablation with biventricular pacing, lead dislodgment was found in one patient and pneumothorax in another. CONCLUSIONS: Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation. (ClinicalTrials.gov number, NCT00599976.) 2008 Massachusetts Medical Society

Do Statins Decrease the Arrhythmia Burden in Patients with Paroxysmal Atrial Fibrillation?

2008-12-11T02:02:00.000-08:00

Citation : Dhanunjaya Lakkireddy.Do Statins Decrease the Arrhythmia Burden in Patients with Paroxysmal Atrial Fibrillation? .JAFIB.2008 Dec;Volume 1 Issue(4): 244-245.

Role of the Autonomic Nervous System in the Creation of Substrate for Atrial Fibrillation

2008-12-11T01:58:00.000-08:00

Citation : Rishi Arora,Alan H. Kadish.Role of the Autonomic Nervous System in the Creation of Substrate for Atrial Fibrillation .JAFIB.2008 Dec;Volume 1 Issue(4): 236-243.

Atrial fibrillation (AF) is the most common sustained arrhythmia disturbance and is associated with significant morbidity and mortality. In recent years, the pulmonary veins (PVs) and posterior left atrium (PLA) have been shown to play a significant role in the genesis of AF.

These regions have been shown to possess unique structural, electrophysiological and calcium (Ca2+) handling characteristics, all of which appear to contribute to substrate for AF.

The pathophysiology of AF is complex, and several mechanisms have been thought to contribute to the electrophysiologic and structural substrate for this arrhythmia. These mechanisms include fibrosis, stretch, inflammation and oxidative stress. In addition, neurohumoral factors have also been invoked for their possible contribution to the creation of electrophysiologic substrate for AF [3, 4]. An important neurohumoral factor that has been studied fairly extensively for its involvement in AF is the autonomic nervous system.

Typical flutter ablation as an adjunct to catheter ablation of atrial fibrillation

2008-12-11T01:45:00.000-08:00

Citation : Dipen Shah.Typical flutter ablation as an adjunct to catheter ablation of atrial fibrillation .JAFIB.2008 Dec;Volume 1 Issue(4): 230-235.

Typical atrial flutter and atrial fibrillation are frequently observed to coexist(1) . In the current context of interventional electrophysiology, curative or at least definitive ablation is available for both arrhythmias. Despite their coexistence, it is not clear whether typical flutter ablation is necessary in all patients undergoing catheter ablation of atrial fibrillation. The following review explores the pathophysiology of both arrhythmias, their interrelationships and the available data pertaining to this theme.

Catheter Ablation for AF: Past, Present, and Future

2008-12-11T01:32:00.000-08:00

Citation : David Spragg,Hugh Calkins.Catheter Ablation for AF: Past, Present, and Future .JAFIB.2008 Dec;Volume 1 Issue(4): 221-229.

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia encountered by physicians. The prevalence of AF in patients over the age of 65 is approximately 6%, and approaches 10% in patients over the age of 85. As the median age of the population in the United States becomes older, the epidemiologic burden of AF in this country will likely increase. Currently approximately 2.2 million people in the United States have AF. AF, while typically not a life-threatening arrhythmia per se, is associated with increased risk of stroke, heart failure, and increased mortality. The stroke risk in patients with AF, for instance, is increased between 5- and 7-fold compared to similar patients without AF.

Periablative Anticoagulation Strategies in Patients with Atrial Fibrillation

2008-12-11T01:29:00.000-08:00

Citation : Fernanda d’Araujo Costa Ferreira, Eduardo B. Saad.Periablative Anticoagulation Strategies in Patients with Atrial Fibrillation .JAFIB.2008 Dec;Volume 1 Issue(4): 216-220.

Atrial fibrillation is associated with thromboembolic events that may cause important impairment on quality of life. Pulmonary vein isolation is the treatment of choice in cases that are refractory to medical therapy. Once sheaths and catheters are manipulated inside the left atrium, anticoagulation with heparin must be used during the procedure to protect patients from thromboembolic phenomena. Different strategies of anticoagulation are used at different centers. This review summarizes the pathophysiology of thrombus formation in the left atrium, defines which patients are under high risk and describes the main strategies used for anticoagulation.

Extraatrial Disease in Patients with “Lone” Atrial Fibrillation

2008-12-11T01:26:00.001-08:00

Citation : Jason Confino,Daniel Edmundowicz,Joan M. Lacomis,Iclal Ocak, Christopher R. Deible,David Schwartzman.Extraatrial Disease in Patients with “Lone” Atrial Fibrillation .JAFIB.2008 Dec;Volume 1 Issue(4): 209-215.

Aims: Lone atrial fibrillation (LAF) is considered by some to be a primary atrial electrophysiologic disorder. However, we have frequently observed evidence of “extraatrial” diseases - atherosclerosis and associated metabolic disorders - in our LAF patients. We sought to characterize and quantify extraatrial disease burden in LAF patients, and to correlate this burden with features of the arrhythmia including pattern (paroxysmal versus persistent) and response to catheter ablation.

Methods and Results: Forty-six consecutive patients with non-familial LAF underwent assessment for evidence of atherosclerosis (computed tomographic vascular calcification and elevated arterial pulse wave velocity) and associated metabolic diseases (dyslipidemia, insulin resistance and inflammation), and then catheter ablation.

The cohort had a significant incidence of atherosclerosis (57%) and metabolic (70%) diseases. Patients with persistent AF tended to have a greater extraatrial disease burden than those with paroxysmal AF. A significant inverse relationship between the rate of ablation success and extraatrial disease burden was demonstrated.

Conclusions: Extraatrial disease was common in this LAF cohort. Correlations between extraatrial disease burden and features of the arrhythmia would, if verified, challenge the notion that LAF is a “primary” electrophysiologic disorder.

Quality of Life, Exercise Capacity and Comorbidity in Old Patients with Permanent Atrial Fibrillation

2008-12-11T01:12:00.000-08:00

Citation :Inger Ariansen,Knut Gjesdal, Michael Abdelnoor, Elisabeth Edvardsen, Steve Enger, Arnljot Tveit.Quality of Life, Exercise Capacity and Comorbidity in Old Patients with Permanent Atrial Fibrillation .JAFIB.2008 Dec;Volume 1 Issue(4): 202-208.

Background: The impact of atrial fibrillation (AF) on quality of life (QoL) differs with the AF population studied and is influenced by comorbidity. In hospital-based studies younger and highly symptomatic patients may be overrepresented. We performed an observational cross sectional study in two municipalities, comparing 75 year-old patients with and without permanent atrial fibrillation, with respect to health-related QoL and exercise capacity, with adjustment for the effects of confounders.
Methods: Maximal treadmill exercise testing provided peak oxygen uptake (VO2 peak). Health-related QoL was assessed by self-completed SF-36 questionnaires. The lowest quartile identified poor outcomes.
Results: 27 subjects with permanent AF and 71 subjects in sinus rhythm participated. AF patients had higher prevalence of compensated chronic heart failure (p < 0.001), valvular heart disease (p < 0.001), lower mean VO2 peak (22.7 ± 5.5 vs. 28.6 ± 6.3 ml/kg/min; p < 0.001), and more often poor VO2 peak; crude OR 5.3 (95%CI 1.8, 15.3), adjusted OR 7.5 (2.0, 28.3). Median Physical Component Summary score (with 25th and 75th percentile) was 41 (31, 51) in AF vs. 52 (45, 55) in controls (p < 0.001). Furthermore, the AF group had higher odds for poor physical QoL scores; crude OR 5.0 (1.8, 13.7), adjusted OR 4.3 (1.5, 12.4). Median Mental Component Summary score was 56 (42, 61) in the AF group vs. 57 (51, 60) in controls (p=0.565). The AF group had non-significantly increased odds for poor mental QoL scores; crude OR 2.3 (0.8, 6.2), adjusted OR 2.8 (1.0, 8.4).
Conclusion: Also after adjustment for confounders, older patients with permanent AF had higher odds for poor exercise capacity and poor physical QoL compared to subjects in sinus rhythm.

Leukocyte Atrial Fibrillation Filtration Study

2008-12-11T00:34:00.000-08:00

Citation : Albert H. O-Yurvati, Steven Rodriguez, Glen Bell,Damon Kennedy, Robert T. Mallet.Leukocyte Atrial Fibrillation Filtration Study .JAFIB.2008 Dec;Volume 1 Issue(4): 194-201.

Abstract

Purpose: Atrial fibrillation remains the leading postoperative complication following cardiopulmonary bypass. A randomized trial was undertaken to evaluate the effectiveness of leukocyte filtration and aprotinin, applied separately and in combination, on the incidence of post-operative atrial fibrillation. A secondary component of the study was the impact of these adjunct interventions on post-surgical renal and neurological dysfunction.

Methods: A total of 1,220 patients undergoing primary isolated coronary artery bypass grafting were randomly assigned to one of four treatment groups. The control group (305 patients) received standard cardiopulmonary bypass with moderately hypothermic (34ºC) cardioplegic arrest. In the filtration group (310 patients) leukocyte reducing filters were incorporated into the bypass circuit. The aprotinin group (285 patients) received full Hammersmith dose aprotinin. The combination therapy group (320 patients) received both aprotinin and leukocyte filtration.

Results: The incidences of atrial fibrillation were 25% in the control group, 16% in the filtration group, 19% in the aprotinin group and 10% in the combination therapy group (P < style=""> Renal dysfunction was detected in 3% of the control group, 2% of the filtration group, 8% of the aprotinin group, and 5% of the combination group (P < style=""> Neurological dysfunction occurred in 2% of the control group, 2% of the filtration group, 1% of the aprotinin group, and 2% of the combination group (P = n.s.).

Conclusions: Combination therapy with aprotinin and leukocyte filtration markedly reduced atrial fibrillation post-cardiopulmonary bypass, and was more effective than the individual treatments. Aprotinin treatment increased the incidence of renal dysfunction, and the addition of leukocyte filtration partially mitigated this detrimental effect of aprotinin.

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

2008-09-16T10:21:00.002-07:00

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

2008-09-16T10:21:00.001-07:00

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

2008-09-16T10:20:00.001-07:00

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.