Background: Lead control has an essential role in successful transvenous lead extraction (TLE), h... more Background: Lead control has an essential role in successful transvenous lead extraction (TLE), however, there is limited data about leads without adequate control Objective: The aim of the study was to assess the success rate, complexity, and safety of partially controlled lead extraction. Methods: A single-center retrospective analysis of consecutive patients underwent TLE procedures was performed. Results: From May 2012 to Aug 2019, 137 consecutive patients (76% male, mean age: 65 ± 15 years) underwent TLE procedures (273 leads, 93% infective indication, 37% with high voltage leads). Locking stylet was used in 83% (n = 224) of the leads. Advancement of the locking stylet all the way to the tip was not possible in 30.4% (n = 68) of the leads, resulting in partial control (LC-group). The mean age of the lead was significantly higher (11.06 +/-vs 7.76 +/-6.3, p = 0.001) and the success rate was lower (76.1 % vs 93.2%, p = 0.001) in LC-. The need for femoral approach was more frequently in LC-leads (36.9% vs 16.2%, P= 0.001). Inadequate lead control was an independent predictor of lead extraction failure (OR: 5.27, 95% CI: 1.71-5.27, p= 0.004) and femoral approach (OR: 2.1, 95% CI: 1.054-4.08, p= 0.035). Three out of five major complications occurred in LC-group. Conclusions: Partial lead control results in lower success rate and more complex TLE procedures.
Background: Detection of concurrent diastolic dysfunction (DD) may be beneficial in patients with... more Background: Detection of concurrent diastolic dysfunction (DD) may be beneficial in patients with persistent and longstanding persistent atrial fibrillation (AF). The role of transthoracic echocardiography (TTE) in assessing DD in patients with AF has not been well characterized. We sought to determine the utility of TTE in detecting elevated left atrial pressure (LAP) in patients with persistent and longstanding persistent non-valvular AF using directly measured LAP as the reference standard. Methods: We retrospectively studied 157 patients with persistent AF and preserved left ventricular ejection fraction who underwent pulmonary vein isolation (PVI). LAP was determined in conjunction with trans-septal puncture at the time of catheter ablation. TTE was performed 1 day after PVI and included two dimensional, pulse wave spectral Doppler and tissue Doppler assessments. Results: The clinical parameter that strongly correlated with elevated LAP is longstanding persistent AF. Four strongest TTE parameters identified to moderately correlate with LAP include 1. left atrial minimum volume (LAVmin), 2. peak velocity of early mitral diastolic inflow velocity (E), 3. pulmonary vein systolic flow velocity (PVS), and 4. ratio of early diastolic transmitral inflow velocity to mitral annular velocity at the lateral site (E/E′ lateral). Conclusion: Accurate assessment of diastolic dysfunction in patients with persistent and longstanding persistent AF is difficult using TTE.
Journal of Cardiovascular Electrophysiology, Mar 30, 2023
IntroductionRoutine ultrasound (US) guidance for femoral venous access to decrease vascular compl... more IntroductionRoutine ultrasound (US) guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized‐trial data.MethodsConsecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi‐random allocation to either US‐guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with a US machine including a vascular transducer. The same four novice operators in rotation, with no relevant previous experience in US‐guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation).ResultsOf the 457 patients 199 were allocated to the US‐guided puncture group, while the conventional, palpation‐based approach was performed in 258 cases. Compared with the conventional technique, US guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p < .0001), including both major (4.26% vs. 1.01%, p = .038) and minor (7.36% vs. 1.01%, p = .001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US‐guided puncture group (5.04% vs. 1.01%, p = .032).ConclusionThe use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi‐randomized comparison strongly supports adapting routine use of US for AF ablation procedures.
Pulmonary vein isolation is associated with silent cerebral ischemic lesions detected by diffusio... more Pulmonary vein isolation is associated with silent cerebral ischemic lesions detected by diffusion-weighted magnetic resonance imaging (MRI), with an incidence between 1% and 40%. Recent studies have shown that these cerebral lesions can occur after radiofrequency ablation for left ventricular extrasystole. Risk of these lesions in conventional ablation has not been evaluated. Aim of this study was to investigate silent cerebral ischemic lesions following left-sided conventional ablation. In a prospective study 296 consecutive patients scheduled for paroxysmal supraventricular tachycardia (PSVT) ablation were screened, and 26 patients meeting study criteria were enrolled. Patients were excluded for age under 18 years or over 80 years, clinically significant neurovascular or valvular disease, proven left atrial thrombus, thrombophilia, previous pacemaker or ICD implantation, documented paroxysmal atrial fibrillation, or any contraindication to MRI. Participants underwent cerebral MRI 24 hours prior and after the ablation, in case of new ischemic lesions a repeated MRI was planned within 3-6 months. Two sequences were used, a 3D T2-weighted fluid-attenuated inversion recovery (FLAIR) and an axial diffusion-weighted (DW) sequence. By definition acute lesions appear as hyperintensities on the postprocedural diffusion-weighted images which correlate with the hypointense signals on the apparent diffusion map and can not be detected on the preprocedural images. patients with and without silent cerebral ischemic lesions who underwent left-sided ablation, and a control group undergoing only right-sided ablation. Groups were compared based on clinical and procedural characteristics. The mean age was 43.9 ± 17.3 years, 42% (n = 11) were men, 35% (n = 9) had a history of hypertension. In all groups radiofrequency energy was used and the ablation was performed with a 4 mm tip non-irrigated catheter. In case of a left-sided procedure left atrium was approached by transseptal puncture controlled by intracardiac echocardiography. Before the transseptal puncture intravenous heparin was administered. Activated clotting time was aimed to be 200-300 seconds. None of the postprocedural MRI in the left-sided or the right-sided group revealed any evidence of new cerebral ischemic lesions. Mean procedural time of left-sided ablations was 176.9 ± 74.7 minutes which was significantly longer (p = 0.0077) compared to the right-sided procedures with 132 ± 72.2 minutes total time. Mean left atrial procedural time was 69.1 ± 7.8 minutes, average ACT was 265 ± 28.2 seconds. No silent ischemic cerebral lesions were detected by MRI after catheter ablation of left-sided PSVT substrate in comparison with the historical population undergoing ablation for atrial fibrillation or ventricular extrasystole. Presumably, cerebral lesions occur at a lower rate or might not appear at all after these less complex procedures.
Journal of Cardiovascular Electrophysiology, Dec 14, 2018
A case of macroreentry tachycardia of the isolated posterior left atrium is presented after surgi... more A case of macroreentry tachycardia of the isolated posterior left atrium is presented after surgical and subsequent catheter ablation.
A bal pitvari fülcse egy alakban és méretben változó előfordulású üreg a szívben, melynek állapot... more A bal pitvari fülcse egy alakban és méretben változó előfordulású üreg a szívben, melynek állapota összefüggést mutat a pitvari aritmiákkal és a thrombus jelenlétével. Tekintettel a bal pitvari fülcse nehézkes ábrázolhatóságára, a jelen összefoglaló célja a különböző echokardiográfiás módszerek szerepének bemutatása.
Pacing and Clinical Electrophysiology, Oct 25, 2013
IntroductionPatients with persistent and longstanding persistent atrial fibrillation (AF) have a ... more IntroductionPatients with persistent and longstanding persistent atrial fibrillation (AF) have a higher recurrence rate after antral pulmonary vein isolation (PVI). We sought to determine the clinical, invasive, and noninvasive diastolic function parameters that are associated with AF recurrence after ablation in patients with persistent and longstanding persistent nonvalvular AF.Methods and ResultsWe studied 125 consecutive patients with persistent and longstanding persistent AF who underwent antral PVI at our institution between April 2009 and April 2011. Standard clinical parameters, left atrial (LA) pressure measured at transseptal puncture, and standard diastolic function parameters on transthoracic echocardiographic (TTE) parameters were assessed. TTE was performed in sinus rhythm the first day following radiofrequency catheter ablation. Ablation eliminated AF in 83 of 125 (66.4%) patients (mean age 61.3 ± 8.9, 81% male) during 17.8 ± 7.7 months of follow‐up. Using logistic regression analysis, AF duration prior to ablation (P = 0.04, odds ratio [OR]: 1.03, 95% confidence interval [CI] 1.0–1.06) was found to be the only clinical parameter significantly associated with AF recurrence. According to multiple logistic regression analysis, the indexed LA minimum volume of 26 cm3/m2 (P = 0.009, OR: 4.9 95% CI 1.5–16.2) was the only independent imaging parameter associated with AF recurrence.ConclusionIndexed minimal LA volume is highly associated with ablation success in patients with persistent and longstanding persistent AF.
Journal of Interventional Cardiac Electrophysiology, Jan 19, 2022
Purpose Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal ... more Purpose Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. Methods In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. Results Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. Conclusions ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
day after the procedure. Emergent surgical correction was required in 2 patients to maintain the ... more day after the procedure. Emergent surgical correction was required in 2 patients to maintain the hemodynamic state. The vast majority of the patients experienced low grade fever and early recurrence of any atrial tachyarrhythmias post cardiac tamponade. One patient experienced cerebral infarction 9 days after the procedure despite the restart of anticoagulation therapy. In one patient, oral steroid therapy was required during 6 months after the procedure for postcardiac injury syndrome. Age, sex, body mass index, type of AF, echocardiographic parameters, serological parameters, and the use of 3D mapping system and irrigation tip catheter were not associated with the incidence. However, the incidence was significantly lower in cryoballoon than radiofrequency ablation (p¼0.046). Conclusions: Careful monitoring and management for cardiac tamponade are necessary not only during the procedure but also after the procedure. Surgical backup and acute management skills for treating tamponade are essential in centers performing AF ablation.
Herzschrittmachertherapie Und Elektrophysiologie, Oct 23, 2020
Left ventricular assist devices (LVAD) are increasingly utilized in the management of patients wi... more Left ventricular assist devices (LVAD) are increasingly utilized in the management of patients with advanced heart failure. Many of these patients have or will be considered for cardiac implantable electronic devices (CIEDs) such as an implantable cardioverter-defibrillator or cardiac resynchronization therapy device. Frequent interplay is often encountered due to complexity of these devices and the underlying disease states. Proactive management strategies and an awareness of interactions may help reduce adverse events. We review current literature, present management recommendations, and discuss potential future investigations for CIEDs in patients with LVADs.
Atrial tachycardias are common after open heart surgery. Most commonly these are macro-reentrant ... more Atrial tachycardias are common after open heart surgery. Most commonly these are macro-reentrant including cavotricuspid isthmus dependent atrial flutter, incisional right atrial flutter and left atrial flutter. Focal atrial tachycardias occur less frequently. The specific type of atrial tachycardia highly depends on the type of surgical incision. Catheter ablation can be very effective, however requires a thorough understanding of anatomy and surgical technique.
Pitvarfibrilláció fennállása esetén a thrombusképződés emelkedett rizikója áll fenn, mely a jobb ... more Pitvarfibrilláció fennállása esetén a thrombusképződés emelkedett rizikója áll fenn, mely a jobb szívfelet is érintheti. A jobb pitvari fülcse nehezen ábrázolható képlet; a jelen összefoglaló célja a rutinban elérhető echokardiográfiás vizsgálómódszerek bemutatása és az ezzel kapcsolatos klinikai adatok ismertetése.
Journal of Interventional Cardiac Electrophysiology, Feb 28, 2019
Purpose Pulmonary vein isolation (PVI) by catheter ablation has reduced efficacy for the treatmen... more Purpose Pulmonary vein isolation (PVI) by catheter ablation has reduced efficacy for the treatment of persistent atrial fibrillation (persAF), as compared to paroxysmal atrial fibrillation (paroxAF). We investigated whether the selection of persAF patients for PVI who Bstep back^to the paroxysmal stage on amiodarone offers a success rate comparable to that of patients with paroxAF. Methods Sixty-two consecutive persAF patients and 62 matched control patients with paroxAF were included. Persistent patients were started on amiodarone and cardioverted to sinus rhythm (SR). PVI was performed after 3 months in those who Bstepped back^and had sustained SR and in all paroxAF patients. Results Five of the 62 (8%) study patients returned to persAF after cardioversion; despite amiodarone, they did not undergo PVI. The rest received PVI and was followed for a mean of 31 ± 14 months. Redo procedures were performed in 44% and 29% in the persAF and paroxAF group (p = 0.093), respectively. The recurrence rate after multiple procedures without antiarrhythmic drugs was similar among the persAF and paroxAF patients (11% and 7%) at 6 months (p = 0.510), but increased in the persAF group at 1 year (21% and 9%, p = 0.065) and exceeded that of the paroxAF group at the end of the follow-up (26% and 12%, p = 0.046). Kaplan-Meier survival analysis showed shorter time to recurrence in the persAF group (p = 0.045). Conclusion PersAF patients who Bstep back^to the paroxysmal stage on amiodarone can expect long-term success of a PVI-only strategy in more than 70% of the time. However, late recurrences are more common compared to paroxAF.
The most common complications of electrophysiology (EP) procedures are related to vascular access... more The most common complications of electrophysiology (EP) procedures are related to vascular access. Our study aimed to compare the ultrasound (US)-guided (Group 1) vs. palpation-based (Group 2) technique for femoral venous access in atrial fibrillation (AF) ablation procedures. Methods Between January 2018 and October 2019, 355 patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. They were allocated to Group 1 or 2 based on which of the two procedure rooms their procedure was scheduled in, with only one of the rooms equipped with an US machine including an 8 MHz linear transducer. Major and minor complications and the rate of prolonged hospitalization were compared in the two groups. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium (BARC) criteria (requiring n...
International Journal of Cardiovascular Imaging, Feb 21, 2015
Clinical echocardiographic assessment of left ventricular (LV) systolic and diastolic function is... more Clinical echocardiographic assessment of left ventricular (LV) systolic and diastolic function is routinely performed following orthotopic heart transplantation (OHT). The purpose of this study was to determine whether echocardiographic indices of LV diastolic function correlate with pulmonary capillary wedge pressure (PCWP) in the transplanted heart. Patients who had OHT between June 2009 and November 2011 underwent transthoracic echocardiography and right heart catheterization (RHC) at approximately 1 year post transplantation. We retrospectively assessed 33 potential parameters of LV diastolic function using 2-dimensional, spectral Doppler and tissue Doppler echocardiography. We measured PCWP by RHC. We compared echocardiographic measures with PCWP using linear regression analysis. Ninetyfive patients (mean age 49 ± 13 years, 73 males, mean LV ejection fraction 62 ± 10 %) were included in the study. Overall, echocardiographic parameters of LV diastolic function demonstrated poor correlation with PCWP. By linear regression, the parameter that most strongly correlated with PCWP was left atrial (LA) minimum area in the apical 4-chamber view (p = 0.002, r 2 = 0.1). Comparing patients with PCWP B 12 mmHg and those with PCWP [ 12 mmHg, the parameter that demonstrated the most significant difference was LA minimum area in the apical 2-chamber view (p = 0.002), and comparing patients with PCWP B 15 mmHg and those with PCWP [ 15 mmHg, the most significant difference was peak early diastolic velocity of the mitral annulus (p = 0.02). In patients with cardiac allografts, clinical echocardiographic measures of LV diastolic function correlate poorly with PCWP.
Background: Lead control has an essential role in successful transvenous lead extraction (TLE), h... more Background: Lead control has an essential role in successful transvenous lead extraction (TLE), however, there is limited data about leads without adequate control Objective: The aim of the study was to assess the success rate, complexity, and safety of partially controlled lead extraction. Methods: A single-center retrospective analysis of consecutive patients underwent TLE procedures was performed. Results: From May 2012 to Aug 2019, 137 consecutive patients (76% male, mean age: 65 ± 15 years) underwent TLE procedures (273 leads, 93% infective indication, 37% with high voltage leads). Locking stylet was used in 83% (n = 224) of the leads. Advancement of the locking stylet all the way to the tip was not possible in 30.4% (n = 68) of the leads, resulting in partial control (LC-group). The mean age of the lead was significantly higher (11.06 +/-vs 7.76 +/-6.3, p = 0.001) and the success rate was lower (76.1 % vs 93.2%, p = 0.001) in LC-. The need for femoral approach was more frequently in LC-leads (36.9% vs 16.2%, P= 0.001). Inadequate lead control was an independent predictor of lead extraction failure (OR: 5.27, 95% CI: 1.71-5.27, p= 0.004) and femoral approach (OR: 2.1, 95% CI: 1.054-4.08, p= 0.035). Three out of five major complications occurred in LC-group. Conclusions: Partial lead control results in lower success rate and more complex TLE procedures.
Background: Detection of concurrent diastolic dysfunction (DD) may be beneficial in patients with... more Background: Detection of concurrent diastolic dysfunction (DD) may be beneficial in patients with persistent and longstanding persistent atrial fibrillation (AF). The role of transthoracic echocardiography (TTE) in assessing DD in patients with AF has not been well characterized. We sought to determine the utility of TTE in detecting elevated left atrial pressure (LAP) in patients with persistent and longstanding persistent non-valvular AF using directly measured LAP as the reference standard. Methods: We retrospectively studied 157 patients with persistent AF and preserved left ventricular ejection fraction who underwent pulmonary vein isolation (PVI). LAP was determined in conjunction with trans-septal puncture at the time of catheter ablation. TTE was performed 1 day after PVI and included two dimensional, pulse wave spectral Doppler and tissue Doppler assessments. Results: The clinical parameter that strongly correlated with elevated LAP is longstanding persistent AF. Four strongest TTE parameters identified to moderately correlate with LAP include 1. left atrial minimum volume (LAVmin), 2. peak velocity of early mitral diastolic inflow velocity (E), 3. pulmonary vein systolic flow velocity (PVS), and 4. ratio of early diastolic transmitral inflow velocity to mitral annular velocity at the lateral site (E/E′ lateral). Conclusion: Accurate assessment of diastolic dysfunction in patients with persistent and longstanding persistent AF is difficult using TTE.
Journal of Cardiovascular Electrophysiology, Mar 30, 2023
IntroductionRoutine ultrasound (US) guidance for femoral venous access to decrease vascular compl... more IntroductionRoutine ultrasound (US) guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized‐trial data.MethodsConsecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi‐random allocation to either US‐guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with a US machine including a vascular transducer. The same four novice operators in rotation, with no relevant previous experience in US‐guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation).ResultsOf the 457 patients 199 were allocated to the US‐guided puncture group, while the conventional, palpation‐based approach was performed in 258 cases. Compared with the conventional technique, US guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p &lt; .0001), including both major (4.26% vs. 1.01%, p = .038) and minor (7.36% vs. 1.01%, p = .001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US‐guided puncture group (5.04% vs. 1.01%, p = .032).ConclusionThe use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi‐randomized comparison strongly supports adapting routine use of US for AF ablation procedures.
Pulmonary vein isolation is associated with silent cerebral ischemic lesions detected by diffusio... more Pulmonary vein isolation is associated with silent cerebral ischemic lesions detected by diffusion-weighted magnetic resonance imaging (MRI), with an incidence between 1% and 40%. Recent studies have shown that these cerebral lesions can occur after radiofrequency ablation for left ventricular extrasystole. Risk of these lesions in conventional ablation has not been evaluated. Aim of this study was to investigate silent cerebral ischemic lesions following left-sided conventional ablation. In a prospective study 296 consecutive patients scheduled for paroxysmal supraventricular tachycardia (PSVT) ablation were screened, and 26 patients meeting study criteria were enrolled. Patients were excluded for age under 18 years or over 80 years, clinically significant neurovascular or valvular disease, proven left atrial thrombus, thrombophilia, previous pacemaker or ICD implantation, documented paroxysmal atrial fibrillation, or any contraindication to MRI. Participants underwent cerebral MRI 24 hours prior and after the ablation, in case of new ischemic lesions a repeated MRI was planned within 3-6 months. Two sequences were used, a 3D T2-weighted fluid-attenuated inversion recovery (FLAIR) and an axial diffusion-weighted (DW) sequence. By definition acute lesions appear as hyperintensities on the postprocedural diffusion-weighted images which correlate with the hypointense signals on the apparent diffusion map and can not be detected on the preprocedural images. patients with and without silent cerebral ischemic lesions who underwent left-sided ablation, and a control group undergoing only right-sided ablation. Groups were compared based on clinical and procedural characteristics. The mean age was 43.9 ± 17.3 years, 42% (n = 11) were men, 35% (n = 9) had a history of hypertension. In all groups radiofrequency energy was used and the ablation was performed with a 4 mm tip non-irrigated catheter. In case of a left-sided procedure left atrium was approached by transseptal puncture controlled by intracardiac echocardiography. Before the transseptal puncture intravenous heparin was administered. Activated clotting time was aimed to be 200-300 seconds. None of the postprocedural MRI in the left-sided or the right-sided group revealed any evidence of new cerebral ischemic lesions. Mean procedural time of left-sided ablations was 176.9 ± 74.7 minutes which was significantly longer (p = 0.0077) compared to the right-sided procedures with 132 ± 72.2 minutes total time. Mean left atrial procedural time was 69.1 ± 7.8 minutes, average ACT was 265 ± 28.2 seconds. No silent ischemic cerebral lesions were detected by MRI after catheter ablation of left-sided PSVT substrate in comparison with the historical population undergoing ablation for atrial fibrillation or ventricular extrasystole. Presumably, cerebral lesions occur at a lower rate or might not appear at all after these less complex procedures.
Journal of Cardiovascular Electrophysiology, Dec 14, 2018
A case of macroreentry tachycardia of the isolated posterior left atrium is presented after surgi... more A case of macroreentry tachycardia of the isolated posterior left atrium is presented after surgical and subsequent catheter ablation.
A bal pitvari fülcse egy alakban és méretben változó előfordulású üreg a szívben, melynek állapot... more A bal pitvari fülcse egy alakban és méretben változó előfordulású üreg a szívben, melynek állapota összefüggést mutat a pitvari aritmiákkal és a thrombus jelenlétével. Tekintettel a bal pitvari fülcse nehézkes ábrázolhatóságára, a jelen összefoglaló célja a különböző echokardiográfiás módszerek szerepének bemutatása.
Pacing and Clinical Electrophysiology, Oct 25, 2013
IntroductionPatients with persistent and longstanding persistent atrial fibrillation (AF) have a ... more IntroductionPatients with persistent and longstanding persistent atrial fibrillation (AF) have a higher recurrence rate after antral pulmonary vein isolation (PVI). We sought to determine the clinical, invasive, and noninvasive diastolic function parameters that are associated with AF recurrence after ablation in patients with persistent and longstanding persistent nonvalvular AF.Methods and ResultsWe studied 125 consecutive patients with persistent and longstanding persistent AF who underwent antral PVI at our institution between April 2009 and April 2011. Standard clinical parameters, left atrial (LA) pressure measured at transseptal puncture, and standard diastolic function parameters on transthoracic echocardiographic (TTE) parameters were assessed. TTE was performed in sinus rhythm the first day following radiofrequency catheter ablation. Ablation eliminated AF in 83 of 125 (66.4%) patients (mean age 61.3 ± 8.9, 81% male) during 17.8 ± 7.7 months of follow‐up. Using logistic regression analysis, AF duration prior to ablation (P = 0.04, odds ratio [OR]: 1.03, 95% confidence interval [CI] 1.0–1.06) was found to be the only clinical parameter significantly associated with AF recurrence. According to multiple logistic regression analysis, the indexed LA minimum volume of 26 cm3/m2 (P = 0.009, OR: 4.9 95% CI 1.5–16.2) was the only independent imaging parameter associated with AF recurrence.ConclusionIndexed minimal LA volume is highly associated with ablation success in patients with persistent and longstanding persistent AF.
Journal of Interventional Cardiac Electrophysiology, Jan 19, 2022
Purpose Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal ... more Purpose Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. Methods In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. Results Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. Conclusions ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
day after the procedure. Emergent surgical correction was required in 2 patients to maintain the ... more day after the procedure. Emergent surgical correction was required in 2 patients to maintain the hemodynamic state. The vast majority of the patients experienced low grade fever and early recurrence of any atrial tachyarrhythmias post cardiac tamponade. One patient experienced cerebral infarction 9 days after the procedure despite the restart of anticoagulation therapy. In one patient, oral steroid therapy was required during 6 months after the procedure for postcardiac injury syndrome. Age, sex, body mass index, type of AF, echocardiographic parameters, serological parameters, and the use of 3D mapping system and irrigation tip catheter were not associated with the incidence. However, the incidence was significantly lower in cryoballoon than radiofrequency ablation (p¼0.046). Conclusions: Careful monitoring and management for cardiac tamponade are necessary not only during the procedure but also after the procedure. Surgical backup and acute management skills for treating tamponade are essential in centers performing AF ablation.
Herzschrittmachertherapie Und Elektrophysiologie, Oct 23, 2020
Left ventricular assist devices (LVAD) are increasingly utilized in the management of patients wi... more Left ventricular assist devices (LVAD) are increasingly utilized in the management of patients with advanced heart failure. Many of these patients have or will be considered for cardiac implantable electronic devices (CIEDs) such as an implantable cardioverter-defibrillator or cardiac resynchronization therapy device. Frequent interplay is often encountered due to complexity of these devices and the underlying disease states. Proactive management strategies and an awareness of interactions may help reduce adverse events. We review current literature, present management recommendations, and discuss potential future investigations for CIEDs in patients with LVADs.
Atrial tachycardias are common after open heart surgery. Most commonly these are macro-reentrant ... more Atrial tachycardias are common after open heart surgery. Most commonly these are macro-reentrant including cavotricuspid isthmus dependent atrial flutter, incisional right atrial flutter and left atrial flutter. Focal atrial tachycardias occur less frequently. The specific type of atrial tachycardia highly depends on the type of surgical incision. Catheter ablation can be very effective, however requires a thorough understanding of anatomy and surgical technique.
Pitvarfibrilláció fennállása esetén a thrombusképződés emelkedett rizikója áll fenn, mely a jobb ... more Pitvarfibrilláció fennállása esetén a thrombusképződés emelkedett rizikója áll fenn, mely a jobb szívfelet is érintheti. A jobb pitvari fülcse nehezen ábrázolható képlet; a jelen összefoglaló célja a rutinban elérhető echokardiográfiás vizsgálómódszerek bemutatása és az ezzel kapcsolatos klinikai adatok ismertetése.
Journal of Interventional Cardiac Electrophysiology, Feb 28, 2019
Purpose Pulmonary vein isolation (PVI) by catheter ablation has reduced efficacy for the treatmen... more Purpose Pulmonary vein isolation (PVI) by catheter ablation has reduced efficacy for the treatment of persistent atrial fibrillation (persAF), as compared to paroxysmal atrial fibrillation (paroxAF). We investigated whether the selection of persAF patients for PVI who Bstep back^to the paroxysmal stage on amiodarone offers a success rate comparable to that of patients with paroxAF. Methods Sixty-two consecutive persAF patients and 62 matched control patients with paroxAF were included. Persistent patients were started on amiodarone and cardioverted to sinus rhythm (SR). PVI was performed after 3 months in those who Bstepped back^and had sustained SR and in all paroxAF patients. Results Five of the 62 (8%) study patients returned to persAF after cardioversion; despite amiodarone, they did not undergo PVI. The rest received PVI and was followed for a mean of 31 ± 14 months. Redo procedures were performed in 44% and 29% in the persAF and paroxAF group (p = 0.093), respectively. The recurrence rate after multiple procedures without antiarrhythmic drugs was similar among the persAF and paroxAF patients (11% and 7%) at 6 months (p = 0.510), but increased in the persAF group at 1 year (21% and 9%, p = 0.065) and exceeded that of the paroxAF group at the end of the follow-up (26% and 12%, p = 0.046). Kaplan-Meier survival analysis showed shorter time to recurrence in the persAF group (p = 0.045). Conclusion PersAF patients who Bstep back^to the paroxysmal stage on amiodarone can expect long-term success of a PVI-only strategy in more than 70% of the time. However, late recurrences are more common compared to paroxAF.
The most common complications of electrophysiology (EP) procedures are related to vascular access... more The most common complications of electrophysiology (EP) procedures are related to vascular access. Our study aimed to compare the ultrasound (US)-guided (Group 1) vs. palpation-based (Group 2) technique for femoral venous access in atrial fibrillation (AF) ablation procedures. Methods Between January 2018 and October 2019, 355 patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. They were allocated to Group 1 or 2 based on which of the two procedure rooms their procedure was scheduled in, with only one of the rooms equipped with an US machine including an 8 MHz linear transducer. Major and minor complications and the rate of prolonged hospitalization were compared in the two groups. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium (BARC) criteria (requiring n...
International Journal of Cardiovascular Imaging, Feb 21, 2015
Clinical echocardiographic assessment of left ventricular (LV) systolic and diastolic function is... more Clinical echocardiographic assessment of left ventricular (LV) systolic and diastolic function is routinely performed following orthotopic heart transplantation (OHT). The purpose of this study was to determine whether echocardiographic indices of LV diastolic function correlate with pulmonary capillary wedge pressure (PCWP) in the transplanted heart. Patients who had OHT between June 2009 and November 2011 underwent transthoracic echocardiography and right heart catheterization (RHC) at approximately 1 year post transplantation. We retrospectively assessed 33 potential parameters of LV diastolic function using 2-dimensional, spectral Doppler and tissue Doppler echocardiography. We measured PCWP by RHC. We compared echocardiographic measures with PCWP using linear regression analysis. Ninetyfive patients (mean age 49 ± 13 years, 73 males, mean LV ejection fraction 62 ± 10 %) were included in the study. Overall, echocardiographic parameters of LV diastolic function demonstrated poor correlation with PCWP. By linear regression, the parameter that most strongly correlated with PCWP was left atrial (LA) minimum area in the apical 4-chamber view (p = 0.002, r 2 = 0.1). Comparing patients with PCWP B 12 mmHg and those with PCWP [ 12 mmHg, the parameter that demonstrated the most significant difference was LA minimum area in the apical 2-chamber view (p = 0.002), and comparing patients with PCWP B 15 mmHg and those with PCWP [ 15 mmHg, the most significant difference was peak early diastolic velocity of the mitral annulus (p = 0.02). In patients with cardiac allografts, clinical echocardiographic measures of LV diastolic function correlate poorly with PCWP.
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Papers by Maria Kohari