OBJECTIVES: The goal of this study was to describe the prevalence and ablation of coronary sinus(CS) arrhythmias after left atrial ablation for atrial fibrillation(AF). OBJECTIVES: The CS has been implicated in a vari...OBJECTIVES: The goal of this study was to describe the prevalence and ablation of coronary sinus(CS) arrhythmias after left atrial ablation for atrial fibrillation(AF). OBJECTIVES: The CS has been implicated in a variety of supraventricular arrhythmias. METHODS: Thirty-eight patients underwent mapping and ablation of atypical flutter that developed during(n=5) or after(n=33) ablation for AF. Also included were two patients with focal CS arrhythmias that occurred during an AF ablation procedure. A tachycardia was considered to be originating from the CS if the post-pacing interval in the CS matched the tachycardia cycle length and/or if it terminated during ablation in the CS. RESULTS: Among the 33 patients who developed atypical flutter late after AF ablation, 9(27%) were found to have a CS origin. Overall, 16 of the 40 patients in this study had a CS arrhythmia. The tachycardia was macro-re-entrant in 14 patients(88%) and focal in two patients. Radiofrequency ablation with an 8-mm-tip catheter was successful in 15 patients(94%) without complication. In eight patients(50%),< 45 W was required for successful ablation. Thirteen of the 15 patients(87%) with a successful ablation acutely remained arrhythmia free during 5±5 months of follow-up. CONCLUSIONS: The musculature of the CS serves as a critical component of the re-entry circuit in approximately 25%of patients with atypical flutter after ablation for AF. The CS may also generate focal atrial arrhythmias that may play a role in triggering and/or maintaining AF. Catheter ablation of these arrhythmias in the CS can be performed safely.展开更多
Background -The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention(PCI). Methods and Results ...Background -The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention(PCI). Methods and Results -Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline(January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention(January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10 287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case(P< 0.05). These changes were associated with lower rates of transfusions, vascular complications, contrast nephropathy, stroke, transient ischemic attack, and combined end points(all P< 0.05). Conclusions -Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a “causal”or a “casual”relationship.展开更多
Background -Because the genesis of atrial fibrillation(AF)is multifactorial and variable, an ablation strategy that involves pulmonary vein isolation and/or a particular set of ablation lines may not be equally effect...Background -Because the genesis of atrial fibrillation(AF)is multifactorial and variable, an ablation strategy that involves pulmonary vein isolation and/or a particular set of ablation lines may not be equally effective or efficient in all patients with AF. A tailored strategy that targets initiators and drivers of AF is a possible alternative to a standardized lesion set. Methods and Results -Catheter ablation was performed in 153 consecutive patients(mean age, 56±11 years) with symptomatic paroxysmal AF with the use of an 8-mm tip radiofrequency ablation catheter. The esophagus was visualized with barium. The pulmonary veins and left atrium were mapped during spontaneous or induced AF. Arrhythmogenic pulmonary veins were isolated or encircled. If AF was still present or inducible, complex electrograms in the left atrium, coronary sinus, and superior vena cava were targeted for ablation. The end point of ablation was absence of frequent atrial ectopy and spontaneous AF during isoproterenol infusion and noninducibility of AF. Routine energy applications near the esophagus were avoided. During follow-up, left atrial flutter developed in 19%of patients and was still present in 10%at >12 weeks of follow-up. A repeat ablation procedure was performed in 18%of patients. During a mean follow-up of 11±4 months, 77%of patients were free from AF and/or atrial flutter without antiarrhythmic drug therapy. Pericardial tamponade or transient neurological events occurred in 2%of procedures. Conclusions -A tailored ablation strategy that only targets triggers and drivers of AF is feasible and eliminates paroxysmal AF in ≈80%of patients.展开更多
文摘OBJECTIVES: The goal of this study was to describe the prevalence and ablation of coronary sinus(CS) arrhythmias after left atrial ablation for atrial fibrillation(AF). OBJECTIVES: The CS has been implicated in a variety of supraventricular arrhythmias. METHODS: Thirty-eight patients underwent mapping and ablation of atypical flutter that developed during(n=5) or after(n=33) ablation for AF. Also included were two patients with focal CS arrhythmias that occurred during an AF ablation procedure. A tachycardia was considered to be originating from the CS if the post-pacing interval in the CS matched the tachycardia cycle length and/or if it terminated during ablation in the CS. RESULTS: Among the 33 patients who developed atypical flutter late after AF ablation, 9(27%) were found to have a CS origin. Overall, 16 of the 40 patients in this study had a CS arrhythmia. The tachycardia was macro-re-entrant in 14 patients(88%) and focal in two patients. Radiofrequency ablation with an 8-mm-tip catheter was successful in 15 patients(94%) without complication. In eight patients(50%),< 45 W was required for successful ablation. Thirteen of the 15 patients(87%) with a successful ablation acutely remained arrhythmia free during 5±5 months of follow-up. CONCLUSIONS: The musculature of the CS serves as a critical component of the re-entry circuit in approximately 25%of patients with atypical flutter after ablation for AF. The CS may also generate focal atrial arrhythmias that may play a role in triggering and/or maintaining AF. Catheter ablation of these arrhythmias in the CS can be performed safely.
文摘Background -The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention(PCI). Methods and Results -Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline(January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention(January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10 287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case(P< 0.05). These changes were associated with lower rates of transfusions, vascular complications, contrast nephropathy, stroke, transient ischemic attack, and combined end points(all P< 0.05). Conclusions -Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a “causal”or a “casual”relationship.
文摘Background -Because the genesis of atrial fibrillation(AF)is multifactorial and variable, an ablation strategy that involves pulmonary vein isolation and/or a particular set of ablation lines may not be equally effective or efficient in all patients with AF. A tailored strategy that targets initiators and drivers of AF is a possible alternative to a standardized lesion set. Methods and Results -Catheter ablation was performed in 153 consecutive patients(mean age, 56±11 years) with symptomatic paroxysmal AF with the use of an 8-mm tip radiofrequency ablation catheter. The esophagus was visualized with barium. The pulmonary veins and left atrium were mapped during spontaneous or induced AF. Arrhythmogenic pulmonary veins were isolated or encircled. If AF was still present or inducible, complex electrograms in the left atrium, coronary sinus, and superior vena cava were targeted for ablation. The end point of ablation was absence of frequent atrial ectopy and spontaneous AF during isoproterenol infusion and noninducibility of AF. Routine energy applications near the esophagus were avoided. During follow-up, left atrial flutter developed in 19%of patients and was still present in 10%at >12 weeks of follow-up. A repeat ablation procedure was performed in 18%of patients. During a mean follow-up of 11±4 months, 77%of patients were free from AF and/or atrial flutter without antiarrhythmic drug therapy. Pericardial tamponade or transient neurological events occurred in 2%of procedures. Conclusions -A tailored ablation strategy that only targets triggers and drivers of AF is feasible and eliminates paroxysmal AF in ≈80%of patients.
