37. heart rhythm society-kongress 2016

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37. HEART RHYTHM
SOCIETY-KONGRESS
2016
4.-7. mai i San Francisco
Peter Schuster, Hjerteavdelingen, Haukeland
universitetssykehus
Det er en lang reise til vestkysten, men årets
Heart Rhythm Society-kongress i San Francisco
var igjen verdt turen. Det ble ikke presentert
revolusjonerende nyheter, men det er verdifullt
i seg selv å få bekreftet at det man gjør er
gjeldende standard. Som i fjor deltok ca. 10-15
norske arytmokardiologer .
Det var 6 norske bidrag, derav 1
paneldeltaker: Hans Henrik Odland fra Oslo
universitetssykehus i sesjonen «Rapid Fire Cases
in Pediatrics and Congenital Heart Disease».
Som dessverre så mange ganger før: referat fra én deltaker, det
er mangelfullt, men …
Når det gjelder ventrikkeltakykardi-ablasjoner, som mange ser
for seg som en enda større (spennende) del av arytmologens fremtid,
er det fortsatt mange forskjellige (overlappende) tilnærminger: lokal
aktivering, kanaler, patologiske signaler, substrathomogenisering og så
videre, uten at noe av dette fremtrer som den åpenbar beste løsningen.
Vi kommer nok til å høre, lese og se mer om dette temaet i fremtiden.
Lungeveneisolasjon er og forblir hjørnesteinen i
ablasjonsbehandlingen for (alle former for) atrieflimmer. Rollen av
ganglion plexus-ablasjon (ved kirurgi) er blitt enda mer usikker enn det
har vært før, og man må da spørre seg hvilken rolle disse spiller ved
transvenøs ablasjon. Det samme gjelder rotorer, fraksjonerte signaler,
linjer med mer. For «hverdags»-lungeveneisolering virker det som om
cryoballongen begynner å spise en større og større andel (med tross alt
gode resultater) av prosedyrene.
NOAK-ene synes å være ganske veletablert før og etter
radiofrekvensablasjon for atrieflimmer. Antidot for en av disse er
tilgjengelig. Manglende mulighet for monitorering av behandlingen
(etterlevelse) før radiofrekvensablasjon løser de fleste fortsatt med
transøsofageal ekkokardiografi før prosedyren.
En interessant supplerende behandlingsmulighet ved fjerning
av pacemakeranlegg er en vena cava-ballong for å kjøpe seg litt tid hvis
det skulle oppstå akutt komplikasjon med ruptur (det hadde i alle fall
ikke jeg hørt om før).
Denne gangen var det en egen «summit» om venstre aurikkellukking. Det vil si at interessen for dette har økt betraktelig, men da var
jeg opptatt med andre foredrag …
Jeg håper at fremtidige referater kan bli noe mer utfyllende, men
da er stedlige redaktører avhengig av hjelp.
hjerteforum
N° 3/ 2016 / vol 29
80
NORSKE
ABSTRAKTER
criteria in patients with definite ARVC from
the Nordic ARVC Registry.
Methods: Patients with definite
ARVC by Task Force 2010 who underwent
SAECG were included in the analysis:
n=160, 62% male, 71% probands, mean
age at diagnosis 42±16 years. EWs were
adjudicated by ECG Core Lab. Filtered
QRS duration (fQRS), duration of terminal
QRS <40 uV (LAS) and root-mean-square
voltage of terminal 40 ms (RMS40) were
assessed in relation to the presence of EW
using receiver-operator characterictics
curve (ROC) analysis and area under the
curve (AUC) measurement. Late potentials
in the SAECG parameters were assessed by
Task Force 2010 definitions.
Results: EW were documented in 10
patients (6%). All three SAECG parameters
were strongly related to the presence of EW
by AUC estimation: fQRS - 0.905, LAS 0.910, RMS40 - 0.899 (p<0.001 for all). All
three SAECG parameters were abnormal in
78 patients (49%) while 33 patients (21%)
did not have late potentials by SAECG. All
10 patients with EW had late potentials in
all three SEACG measures (p=0.011). All
EW patients had other diagnostic criteria
sufficient for ARVC diagnosis. All ten had
either minor or major arrhythmia criterion vs 107of 150 patients without EW
(p=0.039), nine EW patients had major
imaging criterion and eight had repolarisation abnormality.
Conclusions: EW represents an
advanced ventricular depolarization abnormality, is strongly associated with ventricular late potentials by SAECG and arrhythmic
manifestations of ARVC. EW is present only
in patients with clear ARVC phentype determined by other diagnostic criteria and has
minimal contribution to ARVC diagnosis.
PO02-214 / PO02-214 - Epsilon
wave in the Nordic arrhythmogenic right ventricular cardiomyopathy registry: link to ventricular
late potentials and contribution to
diagnosis
Pyotr G. Platonov, MD, PHD, FHRS, Kristina H. Haugaa, MD, PhD, Anneli Svensson,
MD, Henrik K. Jensen, MD, DMSc, Thomas
Gilljam, MD, PhD, Henning Bundgaard, MD,
DMSc, Jim H. Hansen, MD, DMSc, Thor
Edvardsen, MD, PhD and Jesper H. Svendsen,
MD, DMSc. Lund University, Lund, Sweden,
Oslo University Hospital, Rikshospitalet and
University of Oslo, Oslo, Norway, Linköping
University Hospital, Linköping, Sweden, Aarhus University Hospital, Aarhus, Denmark,
Sahlgrenska Academy, Gothenburg, Sweden,
Rigshospitalet - Copenhagen University
Hospital, Copenhagen, Denmark, Gentofte
University Hospital, Gentofte, Denmark
Introduction: Epsilon wave (EW) is a
marker of ventricular depolarization abnormality in patients with arrhythmogenic
right ventricular cardiomyopathy (ARVC),
however high interobserver variability in
assessment of EWs has been reported. Even
though EW is considered a major diagnostic criterion of the disease, it is not clear
to what extent it contributes to diagnosis
or represent a manifestation of advanced
ARVC phenotype. We aimed to (1) determine association between EW and operator-independent quantitative indices of
ventricular depolarisation abnormality using
signal-averaged ECG (SAECG) and (2)
assess EW relationship to other diagnostic
81
hjerteforum
N° 3 / 2016/ vol 29
AB10-04 / AB10-04 Impact of
Acute Atrial Fibrillation Termination and Prolongation of AF Cycle
Length on the Outcome of Ablation
of Persistent AF: A sub-study of the
STAR AF II trial
Results: AF terminated in 8% of
the pulmonary vein isolation (PVI) arm,
45% in the PVI+complex electrogram arm,
and 22% of the PVI+linear ablation arm
(p<0.001) but the 18 month freedom from
AF did not differ between the 3 groups
(p=0.15). Freedom from AF at 18 months
was significantly higher in patients who presented to the lab in sinus rhythm compared
to those who presented in AF but did not
terminate during ablation (63% vs. 44%;
p=0.007). Those who presented in AF but
terminated during ablation had an intermediate outcome (53% AF freedom at 18
months) but this was not significantly different from either those in sinus (p=0.84)
or those who did not terminate (p=0.08).
AF termination was a univariable predictor
of success at 18 months (p=0.007) but
by multivariable analysis, performing PVI
predominantly during sinus rhythm was
the strongest predictor (HR 1.80, p<0.001).
Prolongation of the AFCL was not predictive
of 18 month freedom from AF.
Conclusions: Acute AF termination and
prolongation in AFCL did not predict 18
month freedom from AF. Performing PVI
predominantly during sinus rhythm was the
strongest predictor and could explain better
outcome in patients with early AF termination during ablation.
Simon Kochhäuser, MD, Chenyang Jiang, MD,
Timothy R. Betts, MD, Jian Chen, MD, Isabel
V. Deisenhofer, MD, Roberto Mantovan, MD,
Laurent Macle, MD, Carlos A. Morillo, MD,
FHRS, Wilhelm Haverkamp, MD, Rukshen
Weerasooriya, MD, Jean-Paul Albenque, MD,
Stefano Nardi, MD, PhD, Endrj Menardi, MD,
Paul G. Novak, MD, Prashanthan Sanders,
MD, PhD and Atul Verma, MD, FHRS. University Hospital Münster, Münster, Germany,
Zhejiang Shaoyifu Hospital, Hangzhou,
China, Oxford University Hospitals NHS
Trust, Oxford, United Kingdom, Haukeland
Univ Hospital, Bergen, Norway, Deutsches
Herzzentrum Muenchen, Munich, Germany,
Ospedale Regionale, Treviso, Italy, Montreal
Heart Institute, Montreal, QC, Canada,
Hamilton Health Sciences - McMaster University, Hamilton, ON, Canada, Medizin. Klinik
Schwerpunkt Kardiologie, Berlin, Germany,
Royal Perth Hospital, Perth, Australia,
Clinique Pasteur, Toulouse, France, Presidio
Ospedaliero Pineta Grande, Castel Volturno
(CE), Italy, Azienda Ospedaliera S. Croce e
Carle, Cuneo, Italy, University of Adelaide and
Royal Adelaide Hospital, Adelaide, Australia,
Southlake Regional Health Centre, Newmarket, ON, Canada
PO03-52 / PO03-52 - The forcefrequency relationship of the
failing and dyssynchronous heart
is not changed with resynchronization therapy
Introduction: There is controversy
about the impact of acute atrial fibrillation
(AF) termination and prolongation of AF
cycle length (AFCL) acutely during ablation
on the long-term procedural outcome. We
analyzed the influence of AF termination
and AFCL-prolongation on freedom from AF
in patients from the STAR-AF II trial.
Methods: STAR-AF II was a large,
multicenter trial randomizing 589 patients
with persistent AF to different ablation
strategies. Acute changes in AFCL and AF
termination were collected during the index
procedure and both were compared to
recurrence of AF at 18 months. Recurrence
was defined as AF > 30 seconds based
on ECG, Holters (3,6,9,12,18 months), and
weekly transtelephonic monitor ECGs for 18
months. The impact of AF termination was
also compared to other predictors of procedural outcome by Cox regression analysis.
hjerteforum
N° 3/ 2016 / vol 29
Hans Henrik Odland, MD, PhD, Stian Ross,
MD, Erik Kongsgard, MD, PhD, Thor Edvardsen, MD, PhD, Lars Ove Gammelsrud, MSc
and Richard N. Cornelussen, PhD. Oslo
University Hospital - Rikshospitalet, Oslo,
Norway, Maastricht University, Maastricht,
Netherlands
Introduction: Resynchronization
therapy is an effective treatment of heart
failure patients with left bundle branch
block. Little is known about the myocardial
force-frequency responses (FFR) in these
patients. Dyssynchronous contraction may
hamper the inotropic response resulting
from changes in heart frequencies.
Methods: In 26 patients who underwent CRT with class I indications a left ven-
82
ablation effectiveness has not been clearly
elucidated in the human heart.
Methods: 416 ablation points were
acquired from 19 patients with paroxysmal
atrial fibrillation who underwent pulmonary
vein isolation for the first time. A Thermocool SmartTouch ablation catheter was
used. Ablation time, power, contact force
and impedance were recorded and used to
calculate Ablation index (AbI) by a customized formula (Figure). Impedance drop
(ID) was used to evaluate ablation effect.
ID≥10Ω was regarded as an adequate lesion
formation. The real-time ID under various
AbI and total AbI after 60s ablation were
calculated. Data were also grouped by
different power applications (25W, n=115,
30W, n=166, and 35W, n=135).
Results: ID rose 3.7±2.8, 8.3±4.9,
10.8±6.9, 12.6±7.8, 16.1±8.6, 19.6±12.8 Ω
when AbI reached 100, 200, 300, 400,
500 and 600 W·g·s, respectively (P<0.01).
Under power setting of 25W, ID was lower
than that under 30W and 35W at the same
AbI level. There was no significant difference of ID between 30W and 35W except
AbI was at level of 300 W·g·s. Average AbI
in the group that ID never crossed 10Ω was
lower than that in the group with ID≥10Ω
(Table). To reach ID≥10Ω, minimum AbI of
400 W·g·s were needed at 25W, while only
300 W·g·s needed at 30W or 35W.
Conclusions: AbI correlated with the ID
indicating ablation effect during atrial fibrillation ablation. A cutoff value of 400 W·g·s
at 25w and 300 W·g·s at ≥30W might
be used for predicting an adequate lesion
formation.
tricular pressure catheter was placed and
pacing was performed first with the LV lead
in a suboptimal anterior or apical position,
then with the LV lead in an optimal lateral
position. FFR was performed by sequential
pacing in both positions with a pacing train
of 8 beats (beat 1, paced cycle length, PCL,
640±2ms) coupled to a pacing train (beat
3) with a longer PCL (810±7ms), still above
the intrinsic rate. The first beat of the second pacing train is potentiated, termed beat
2. Response was measured as dP/dTmax
(mmHg/s) and linear mixed models were
used with all values presented as estimated
marginal Mean±SEM (mmHg/s).
Results: Pacing resulted in a
significant increase from beat 1 to 2 and
a decrease to beat 3; A pacing 795±35 to
903±35 to 765±34; RV pacing 834±40
to 932±40 to 758±39; LV pacing 900±50
to 1039±49 to 835±48; BiVP 845±41 to
987±41 to 765±39. A significant (p<0.01)
impact on the intercept of the interaction
between position and beat on dP/dTmax
was found with BiV pacing (ant/apical
840±40 vs lateral 947±40) and LV pacing
(ant/apical 912±50 vs lateral 958±50). No
differences were found between pacing LV
only or BiV in optimal and suboptimal positions with respect to beat 1, 2 and 3.
Conclusions: A force-frequency
response with an increase in dP/dTmax
and a subsequent decrease is seen with
all pacing modalities in both optimal and
suboptimal positions, however qualitatively
different with pacing at optimal sites. This
suggests that FFR is present, and may be
modulated with resynchronization, even in
dyssynchronous failing hearts.
AB31-03 / AB31-03 - Cross Mapping Can Identify the Mechanisms
of Atrial Tachycardia Post Atrial
Fibrillation Ablation
PO04-99 / PO04-99 - Ablation
index correlates with impedance
drop during catheter ablation of
atrial fibrillation
Yu-Chuan Wang, MD, Li-Bin Shi, MD, Alessandro De.Bortoli, MD, PhD, Li-Zhi Sun, MD,
PhD, Hoff Per.Ivar, MD, Eivind Solheim, MD,
PhD, Peter.Moritz Schuster, MD, PhD, OleJørgen Ohm, MD, PhD and Jian Chen, MD,
PhD. Haukeland University Hospital, Bergen,
Norway
Li-Bin Shi, MD, Yu-Chuan Wang, MD, Peter
Schuster, MD, PhD, Alessandro De Bortoli,
MD, Li-Zhi Sun, MD, Per Ivar Hoff, MD,
Eivind Solheim, MD, PhD, Ole-Jørgen Ohm,
MD, PhD and Jian Chen, MD, PhD. Haukeland
University Hospital, Bergen, Norway
Introduction: Fractionated potentials
(FP), covering nearly half of tachycardia
cycle length (TCL), are often observed in
atrial tachycardia (AT) post atrial fibrillation
Introduction: The correlation
between ablation index (AbI) and lesion
depth has been proved in animal studies.
However, the relationship between AbI and
83
hjerteforum
N° 3 / 2016/ vol 29
and BD/TCL in group I was 54±23% and
41±25%, was 15±21% and 9±11%, respectively in group II. TDR ≥25% was used as
the cut-off value for predicting mAT. The
positive and negative predictive value was
71.4% and 100.0%, respectively, with sensitivity of 100.0% and specificity of 83.3%.
Conclusions: Cross mapping can differentiate culprit FPs from bystander FPs in
mAT. Both cross over values of TDR ≥25%
can be used as a key parameter.
(AF). Some of these FPs present substrates
for micro-reentrant AT (mAT), while others
are bystander during AT. We investigated
a method of cross mapping to identify the
culprit FPs for mAT.
Methods: Mechanisms of ATs post
AF were recognized by mapping. mAT
was defined as a vortex-like conduction
around a minuscule core (diameter<5mm)
without any discernable obstacle. Cross
mapping was performed: 1) Local activation
times of 4 points (A, B, C and D, Figure)
taken closely and evenly around a FP were
measured. 2) The differences of local
activation time between A and C, B and D
were calculated. 3) Time difference
ratios (TDR), the difference of local
activation time divided by TCL (AC/
TCL and BD/TCL), were calculated.
Results: Totally 19 patients
(60.5±9.1 years, 15 men) with
successful ablation of ATs post
AF ablation were enrolled. After
3-dimesional mapping, 14 FPs (group
I) were indicated as substrate for
mAT, while 20 FPs (group II) were
bystanders for mAT episode. After
cross mapping, the mean of AC/TCL
hjerteforum
N° 3/ 2016 / vol 29
84

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