Not Safe at Any Velocity

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 14, No. 1Not Safe at Any Velocity Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBNot VelocityLeft Atrial Appendage Emptying Cessation of Anticoagulation After Electrical Isolation Ayman A. Hussein, MD Wael Jaber, Oussama M. WazniMD HusseinAyman Hussein Department Cardiovascular Medicine, Section Cardiac Pacing Electrophysiology (A.A.H., O.M.W.), Cleveland Clinic, OH. Search for more papers by this author , JaberWael Jaber https://orcid.org/0000-0001-5642-2112 WazniOussama Wazni Correspondence to: Wazni, MD, Electrophysiology, J2-2, 9500 Euclid Ave, Cleveland, OH 44195. Email E-mail Address: [email protected] https://orcid.org/0000-0001-7115-7716 Imaging (W.A.J.), Originally published19 Jan 2021https://doi.org/10.1161/CIRCEP.120.009409Circulation: Electrophysiology. 2021;14:e009409This article is a commentary on the followingLong-Term Outcomes Left in Patients With Nonparoxysmal FibrillationCatheter-based ablation targeting pulmonary vein isolation has become widely used first-line therapy patients with paroxysmal atrial fibrillation (AF) excellent safety efficacy. In persistent longstanding AF, outcomes remain suboptimal due complex substrate advanced left adverse remodeling. Multiple strategies which target modification have been proposed over past decade improve clinical nonparoxysmal AF without clear benefit.See Article Romero et alIn addition isolation, appendage (LAA) as source triggers or localized reentry1,2 was shown multiple studies arrhythmia-free survival.1,3–8 However, concerns remained regarding such practice especially related increased stroke risk from loss LAA contractility following electrical inherently stasis.In November 2020 issue journal, al9 present long-term (LAAEI) using propensity-matched cohorts. From prospective registry getting between 2010 2014, 5 years were assessed 546 who did not undergo LAAEI. The overall freedom arrhythmia recurrence, off antiarrhythmic drugs, higher LAAEI compared those get (68.9% versus 50.2%, P<0.001). This achieved risks acute procedural complications. Oral anticoagulation continued group CHA2DS2-VASc score ?2 but recurrences 6 months postablation group, transesophageal echocardiography (TEE) guide further management. oral discontinued emptying velocity >0.4 m/s upon TEE assessment regardless score, whereas lifelong OAC encouraged all impaired (<0.4 m/s) even low scores 0 1. Upon follow-up, no thromboembolic events occurred either groups whenever continued; among taken OAC, 9.1% 1.2% non-LAAEI (P<0.001).The study highlights well-established role arrhythmogenesis confirms prior observations better rates While confirmatory nature, adds knowledge showing that benefit sustained during follow-up.The also certain considerations need be highlighted are essential safety; particular, ablating ostially relying intracardiac real-time monitoring catheter tissue contact position avoid perforation. Furthermore although injury low, operators aware nearby structures phrenic nerve circumflex artery.The most important observation guided cessation maintained sinus rhythm after simply safe. patients, 9-folds when stopped anticoagulation. LAA, function would appreciated assessment. It possible any reflect reconnection could associated delayed intermittent activation flow within time thought normal. Another caveat stopping asymptomatic can predispose clearly factor profiles. Given spatial continuity atrium, it only assess surrogate return mechanical pulse Doppler across mitral valve focus A wave size marker electric resumption atrium. Both high large may provide protection against clot formation stroke. authors here others should investigate quantum entanglement its impact decisions prevention.Due lack robust data successful ablation, continues key decisions. There caveats approach prediction performance setting, many individual components known both risk, separately independently. supports use we acknowledge tools needed. magnetic resonance imaging biomarkers atriopathy remodeling guiding yet fully investigated. Similarly, randomized trials still lacking.Nonetheless, clinicians lenient keeping anticoagulation, era direct anticoagulants ease cumulative data; apixaban. our practice, favor continuation success their score. alternative setting subsequent closure. All above considered, do systematically perform AF. typically reserved repeat procedures veins posterior wall found electrically silent. Ablation base an option preserves while potentially improving outcomes. efficacy determined.The takeaway message feasible acutely Nonetheless pending research data, come commitment success, importantly velocities. When comes down velocities latter safe speed.Sources FundingNone.Disclosures Dr receives consulting honoraria Pfizer grant support Boston Scientific. Biosense Webster.FootnotesThe opinions expressed necessarily editors American Heart Association.For Sources Funding Disclosures, see page 10.Correspondence protected]orgReferences1. Di Biase L, Burkhardt JD, Mohanty P, Sanchez J, S, Horton R, Gallinghouse GJ, Bailey SM, Zagrodzky Santangeli al.. appendage: underrecognized trigger site fibrillation.Circulation. 2010; 122:109–118. doi: 10.1161/CIRCULATIONAHA.109.928903LinkGoogle Scholar2. Hocini M, Shah AJ, Nault I, Sanders Wright Narayan Takahashi Y, Jaïs Matsuo Knecht Localized reentry arrhythmogenic undergoing fibrillation.Heart Rhythm. 2011; 8:1853–1861. 10.1016/j.hrthm.2011.07.013CrossrefMedlineGoogle Scholar3. JE, Trivedi C, Güne? Göko?lan Gianni RP, ablation: BELIEF trial.J Am Coll Cardiol. 2016; 68:1929–1940. 10.1016/j.jacc.2016.07.770CrossrefMedlineGoogle Scholar4. Panikker Jarman JW, Virmani Kutys Haldar Lim E, Butcher Khan H, Mantziari Nicol concomitant device occlusion treat fibrillation: first-in-human safety, feasibility, study.Circ Arrhythm Electrophysiol. 9:e003710. 10.1161/CIRCEP.115.003710LinkGoogle Scholar5. Yorgun Canpolat U, Kocyigit D, Çöteli Evranos B, Aytemir K. one-year outcome cryoballoon-based ablation.Europace. 2017; 19:758–768. 10.1093/europace/eux005CrossrefMedlineGoogle Scholar6. Lakkireddy Mahankali AS, Kanmanthareddy A, Lee Badhwar N, Bartus K, Atkins Bommana Cheng Rasekh ligation LAALA-AF registry.J Cardiol EP. 2015; 1:153–160.Google Scholar7. Park HC, Shim Choi JI, Kim YH. caused extensive anterior fibrillation.J Interv Card 46:287–297. 10.1007/s10840-016-0116-7CrossrefMedlineGoogle Scholar8. Bordignon Fuernkranz Dugo Konstantinou Schullte Hahn Nowak Chun KRJ, Schmidt B. comprehensive percutaneous MAZE-like followed closure.J Cardiovasc 2017.Google Scholar9. Patel Parides Alviz Diaz JC, Natale V, Long-term propensity score-matched analysis.Circ 2020; 13:e008390. 10.1161/CIRCEP.120.008390LinkGoogle Scholar Previous Back top Next FiguresReferencesRelatedDetailsRelated articlesLong-Term FibrillationJorge Romero, al. Circulation: 2020;13 January 2021Vol Issue 1Article InformationMetrics Download: 106 © 2021 Association, Inc.https://doi.org/10.1161/CIRCEP.120.009409PMID: 33464945 publishedJanuary 19, KeywordsEditorialsatrial appendageatrial fibrillationcatheter ablationradiofrequency ablationstrokePDF download SubjectsComplicationsCatheter Implantable Cardioverter-DefibrillatorAtrial Fibrillation