MEDICAL DIARY - The Federation of Medical Societies of Hong Kong
MEDICAL DIARY - The Federation of Medical Societies of Hong Kong MEDICAL DIARY - The Federation of Medical Societies of Hong Kong
28 Fig. 1 CBCT machine Medical Bulletin 2. Segmental ablation- There is an extension of left atrium muscle to the PV. Therefore, ablation at the ostium of PV using a Lasso catheter can easily identify the breakthrough sites from left atrium (LA) to PV. Pappone using the Carto system (3D mapping system) applied circumferential ablation of PV orifice. He reported that there was more than 80 % successful rate. VOL.14 NO.1 JANUARY 2009 3. Linear ablation- The left atrial wall especially the left posterior left atrium is involved in the initiation and maintenance of AF. Therefore, ablation of the left atrial wall, PV ostial atrial tissues and mitral annulus atrial tissues are necessary in treating chronic AF. The noninducibility of AF as end point for linear ablation in Bordeaux group increased the successful rate of AF ablation. b) Other Thoracic Foci of AF SA node derives from sinus venosus embryologically. However, there are other areas of thoracic veins which are also remnants of sinus venosus such as SVC, coronary sinus, etc. 1. 2. 3. 4. 5. Superior vena cava (SVC) - The junction between SVC and right atrium contains myocytes that has pacemaker activity. If there is enhanced automaticity this will play as a trigger for AF. Clinical study confirmed that there is a layer of myocardial tissue on the dorsal surface of SVC Coronary sinus (CS) - In animal studies, there is automatic rhythmic activity triggered by catecholamines. Clincially, we prove that there are a lot of fractionated potentials in CS. Crista Terminalis - Hogan found that there are atrial fibres all along the border of crista terminalis which has spontaneous discharge. This may also account for initiation of AF. Ligament of Marshall- It is the embryonic sinus venosus and left cardinal vein running between the superior and inferior left pulmonary veins. It is found that there is atrial musculature which runs in from coronary sinus. This musculature has also been found to have triggered activity. Left sided posterior atrial wall- For diseased atria, the musculature is hypopolarised and can produce ectopics which may trigger AF. The mechanism may be slow depolarisation of phase 4 or delayed after depolarisation triggers after isoprenalin. Non- PV ectopics account for around 25% of patients who have recurrences of AF. 15-25 % of patients actually have non-PV triggers. Complex Fractionated Atrial Electrograms CFAE Another approach of ablating AF suggested by Professor Nademanee is to ablate the Complex Fractionated atrial electrograms (CFAE): Defined : 2 deflections or more with fluctuating baseline or atrial electrograms with a very short cycle length (< 120 msec). It was thought that by ablating the CFAE, the ganglionic plexi (GP) will be modified. Therefore , the maintenance substrate of AF was also modified too.
VOL.11 VOL.14 NO.5 NO.1 MAY JANUARY 2006 2009 Post Ablation Management We start anticoagulation after 4 hours of sheath removal. Nowadays we usually use the LMWH. Oral warfarin is also started at the same time. We anticoagulate the patient for around 30 days. Anticoagulation will be stopped after 3 months treatment if there is no more AF recurrence. Anti- arrhythmic drugs are also prescribed for 1-3 months. Breakthrough attacks of AF and atrial tachyarrhythmia are quite common within the 1st month. Therefore, we can only label success or not after at least 1 month's time. Complications Pericardial effusion 0.1% Stroke 0.03% TIA 0.2 % Cardiac tamponade 0.1% Severe PV stenosis 1% Phrenic nerve palsy 0.5 % atrio- oesophageal fistula 0.05% atrial flutter or tachyarrhythmia 5-10 % Death 70 yrs old); underlying heart disease etc. References Medical Bulletin 1. HK-IN-PACE 10 th Annual Scientific meeting:- AF presentations by Professor Zhang Shu. 2. Effects of rapid atrial pacing on the arrhythmogenic activity of single cardiomyocytes from PV:- Chen YJ, Chen SA,Chen YC. Circulation 2001;104:2849-2854 3. Evidence of specialized conduction cells in human pulmonary veins of patients with AF. Perez-Lugones A, McmahonJT, Ratliff NBet al. J Cardiovasc Electrophysiology 2003; 14:803-809 4. A focal source of of AF treated by discrete RF ablation. Jais P, Haissaguerre M,Shah Dc. Circulation 1997;95:572-576. 5. Spontaneous initiation of AF by ectopic beats originating in the PV. N Eng J Med 1998;339:659-666 6. Architecture of the PV:- relevance to RF ablation. Heart 2001;86:265-270. Ho SY, Cabrere JA. 7. Initiations of AF by ectopic beats originating from the SVC: electrophysiological characteristics and results of RF ablation. Circulation 2000; 102:67-74. Tsai CF, Tai CT, Hsieh MH. 8. Circumferential RF ablation of PV :- a new anatomic approach for curing AF. Circulation 2000; 102:2619-2628. PapponeC, Rosanio S, oreto G 9. Morbidity, mortality and QOL after circumferential PV ablation for AF. J Am Coll Cardiol 2003; 42:185-197. 10. Mechanisms for impulse initiation in isolated human atrial fibers. Circ Res 1980; 47:267-277. Mary-RabineL, Hordof AJ, Danilo P Jr 11. Electrophysiological properties of diseased human atrium. Circ Res 1979;44:545-557.Gelband H, Bush HL 12. Evaluation of pulmonary vein stenosis after catheter ablation of AF. Card Electrophyiol Rev 2002;6:397-400. Tsao HM, Chen SA. 13. Catheter ablation of chronic AF targeting the initiating triggers. Haissaguerre M,Jais P,Shah DC et al. J Cardiovasc Electrophysiol 2000; 11:2-10. 14. AF originating from persistent left SVC. HsuLF, Jais p, Keane D. Circulation 24;109:828-832, 2004. 15. Nonpulmonary vein foci: Do they exist? Shah DC, HaissaguerreM, Jais P, Hocinic M. Pacing Clin Electrophysiol 26:1631-1635, 2003. 16. Spread of excitation from the atrium into thoracic veins in human beings and dogs. Spach MS, BarrRC, Jewett PH. Am J Cardiol 30:844- 854, 1972. 17. Pulmonary vein isolation for paroxysmal and persistent AF. Oral H,Knight BP,Tada H. Circulation 105:1077-1081, 2002. 18. 18. Coronary sinus as an arrhythmogenic structure. Chen PS, Chou CC. j Cardiovasc Electrophysiol 13:863-864, 2002. 19. Mother rotors and fibrillatory conduction: A mechanism of AF. Jalife J, berenfeld O, Mansour M. Cadiovasc Res 54:204-216, 2002 20. Catheter induced linear lesions in the LA in patients with AF. Ernst S, Ouyand F, Lober F, et al. J Am Coll Cardiol 42:1271-1282, 2003. 21. Left atrial tachycardia after circumferential pulmonary vein ablation for AF. Mesas CE, Pappone C, Lang CCE. J Am Coll Cardiol 44:1071- 1079, 2004. THE FEDERATION OF MEDICAL SOCIETIES OF HONG KONG � � � � � � � � 29
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VOL.11 VOL.14 NO.5 NO.1 MAY JANUARY 2006 2009<br />
Post Ablation Management<br />
We start anticoagulation after 4 hours <strong>of</strong> sheath<br />
removal. Nowadays we usually use the LMWH. Oral<br />
warfarin is also started at the same time. We<br />
anticoagulate the patient for around 30 days.<br />
Anticoagulation will be stopped after 3 months<br />
treatment if there is no more AF recurrence. Anti-<br />
arrhythmic drugs are also prescribed for 1-3 months.<br />
Breakthrough attacks <strong>of</strong> AF and atrial tachyarrhythmia<br />
are quite common within the 1st month. <strong>The</strong>refore, we<br />
can only label success or not after at least 1 month's time.<br />
Complications<br />
Pericardial effusion 0.1%<br />
Stroke 0.03%<br />
TIA 0.2 %<br />
Cardiac tamponade 0.1%<br />
Severe PV stenosis 1%<br />
Phrenic nerve palsy 0.5 %<br />
atrio- oesophageal fistula 0.05%<br />
atrial flutter or tachyarrhythmia 5-10 %<br />
Death 70 yrs old); underlying heart disease etc.<br />
References<br />
<strong>Medical</strong> Bulletin<br />
1. HK-IN-PACE 10 th Annual Scientific meeting:- AF presentations by<br />
Pr<strong>of</strong>essor Zhang Shu.<br />
2. Effects <strong>of</strong> rapid atrial pacing on the arrhythmogenic activity <strong>of</strong> single<br />
cardiomyocytes from PV:- Chen YJ, Chen SA,Chen YC. Circulation<br />
2001;104:2849-2854<br />
3. Evidence <strong>of</strong> specialized conduction cells in human pulmonary veins <strong>of</strong><br />
patients with AF. Perez-Lugones A, McmahonJT, Ratliff NBet al. J<br />
Cardiovasc Electrophysiology 2003; 14:803-809<br />
4. A focal source <strong>of</strong> <strong>of</strong> AF treated by discrete RF ablation. Jais P,<br />
Haissaguerre M,Shah Dc. Circulation 1997;95:572-576.<br />
5. Spontaneous initiation <strong>of</strong> AF by ectopic beats originating in the PV. N<br />
Eng J Med 1998;339:659-666<br />
6. Architecture <strong>of</strong> the PV:- relevance to RF ablation. Heart 2001;86:265-270.<br />
Ho SY, Cabrere JA.<br />
7. Initiations <strong>of</strong> AF by ectopic beats originating from the SVC:<br />
electrophysiological characteristics and results <strong>of</strong> RF ablation.<br />
Circulation 2000; 102:67-74. Tsai CF, Tai CT, Hsieh MH.<br />
8. Circumferential RF ablation <strong>of</strong> PV :- a new anatomic approach for curing<br />
AF. Circulation 2000; 102:2619-2628. PapponeC, Rosanio S, oreto G<br />
9. Morbidity, mortality and QOL after circumferential PV ablation for AF.<br />
J Am Coll Cardiol 2003; 42:185-197.<br />
10. Mechanisms for impulse initiation in isolated human atrial fibers. Circ<br />
Res 1980; 47:267-277. Mary-RabineL, Hord<strong>of</strong> AJ, Danilo P Jr<br />
11. Electrophysiological properties <strong>of</strong> diseased human atrium. Circ Res<br />
1979;44:545-557.Gelband H, Bush HL<br />
12. Evaluation <strong>of</strong> pulmonary vein stenosis after catheter ablation <strong>of</strong> AF.<br />
Card Electrophyiol Rev 2002;6:397-400. Tsao HM, Chen SA.<br />
13. Catheter ablation <strong>of</strong> chronic AF targeting the initiating triggers.<br />
Haissaguerre M,Jais P,Shah DC et al. J Cardiovasc Electrophysiol 2000;<br />
11:2-10.<br />
14. AF originating from persistent left SVC. HsuLF, Jais p, Keane D.<br />
Circulation 24;109:828-832, 2004.<br />
15. Nonpulmonary vein foci: Do they exist? Shah DC, HaissaguerreM, Jais<br />
P, Hocinic M. Pacing Clin Electrophysiol 26:1631-1635, 2003.<br />
16. Spread <strong>of</strong> excitation from the atrium into thoracic veins in human<br />
beings and dogs. Spach MS, BarrRC, Jewett PH. Am J Cardiol 30:844-<br />
854, 1972.<br />
17. Pulmonary vein isolation for paroxysmal and persistent AF. Oral<br />
H,Knight BP,Tada H. Circulation 105:1077-1081, 2002.<br />
18. 18. Coronary sinus as an arrhythmogenic structure. Chen PS, Chou CC. j<br />
Cardiovasc Electrophysiol 13:863-864, 2002.<br />
19. Mother rotors and fibrillatory conduction: A mechanism <strong>of</strong> AF. Jalife J,<br />
berenfeld O, Mansour M. Cadiovasc Res 54:204-216, 2002<br />
20. Catheter induced linear lesions in the LA in patients with AF. Ernst S,<br />
Ouyand F, Lober F, et al. J Am Coll Cardiol 42:1271-1282, 2003.<br />
21. Left atrial tachycardia after circumferential pulmonary vein ablation<br />
for AF. Mesas CE, Pappone C, Lang CCE. J Am Coll Cardiol 44:1071-<br />
1079, 2004.<br />
THE FEDERATION OF <strong>MEDICAL</strong> SOCIETIES OF HONG KONG<br />
� � � � � � � �<br />
29
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