Atrial Fibrillation (eBook)

Preface 7
Acknowledgment 9
Contents 11
Contributors 15
Introduction: Epidemiology of Atrial Fibrillation and Impact on Health System 23
Epidemiology of Atrial Fibrillation 24
Prevalence 25
Incidence 28
References 29
Economic Costs Associated with Atrial Fibrillation 34
Economic Considerations 35
Atrial Fibrillation Evaluation and Treatment 39
Future Directions 42
References 43
Introduction 48
Cost-Effectiveness of Catheter Ablation for Atrial Fibrillation 48
Cost-Effectiveness Analysis 49
Cost-Effectiveness of Pharmacological Rhythm vs Rate Control Strategies 49
Cost-Effectiveness of Radio-Frequency Ablation of Atrial Fibrillation 49
Conclusions 52
References 53
Pathophysiology, Molecular Mechanisms, and Genetics of Atrial Fibrillation 56
Cellular Electrophysiology and the Substrate for Atrial Fibrillation 58
Basics of Normal Atrial Cellular Electrophysiology 58
Acquired Substrates for Atrial Fibrillation 61
Genetic Substrates for Atrial Fibrillation 67
Conclusions 70
References 70
Electrical and Structural Remodeling in Atrial Fibrillation 78
Atrial Electrophysiological Remodeling 79
Summary and Future Directions 85
References 85
Genetics of Atrial Fibrillation: The Clinician’s Perspective 90
Introduction 90
Molecular Mechanisms in Atrial Fibrillation 91
Genetic Studies: Implications for the Future 94
References 95
Dominant Frequency Mapping to Assess the Consequences of Remodeling in the Mechanism of Atrial Fibrillation 98
Introduction 99
Mechanisms of Atrial Fibrillation 99
Paroxysmal and Persistent Atrial Fibrillation 100
Acute Atrial Fibrillation: The Sheep Heart Model 101
Role of Atrial Structure 104
Role of Dispersion of Action Potential Duration and Refractoriness 105
Atrial Fibrillation in Chronically Instrumented Animal Models 107
Activation Rate in Atrial Fibrillation 107
Radio-Frequency Ablation of Atrial Fibrillation 108
Cycle Length During Atrial Fibrillation in Humans 110
Mapping Dominant Frequencies in Patients with Atrial Fibrillation 111
How Stable Is Atrial Fibrillation and How Reliable Is Dominant Frequency Mapping? 114
References 115
Intracellular Calcium Dynamics and Atrial Fibrillation 122
Automaticity, Triggered Activity, and Reentry 123
Electrophysiological Remodeling and Atrial Dysfunction in Atrial Fibrillation 123
Intracellular Calcium Overload and Atrial Fibrillation 124
Spontaneous Electrical Activities of the Pulmonary Veins 125
Pacemaking Cells in the Pulmonary Veins 125
Cellular Electrophysiology of Pulmonary Vein Cardiomyocytes 126
Mechanisms of Focal Activities Underlying Pulmonary Vein Arrhythmogenesis of Atrial Fibrillation 127
Dual-Optical Mapping of Canine Pulmonary Veins 127
Late Phase 3 Early Afterdepolarization Contributing to Initiation of Atrial Fibrillation 129
Conclusion 130
References 131
Introduction 136
Role of the Vagus in AF 136
The Cardiac Autonomic Nervous System 137
Pathophysiology of Vagal Control in Atrial Fibrillation 138
Vagal Denervation and Inducibility of Atrial Fibrillation 140
Vagal Denervation and Postoperative Atrial Fibrillation 143
Vagal Nerve Stimulation: A Novel Strategy for Ventricular Rate Control During Atrial Fibrillation 144
Conclusion 146
References 147
Atrial Fibrillation Genetic Considerations: The Basic Scientist’s Perspective 154
Introduction 154
Genetic Component of Atrial Fibrillation 155
Classification of Atrial Fibrillation Genes: Disease-Causing Genes, Susceptibility Genes, and Disease- Linked Genes 156
Genomewide Single Nucleotide Polymorphism Association Studies 160
Future Perspectives 160
References 161
Medical Treatment in Atrial Fibrillation 166
Review of Recent Trials of Medical Therapy for Atrial Fibrillation 168
Introduction 168
Trials of Pharmacological Rate Control 169
Trials of Pharmacological Rhythm Control 172
Trials of Pharmacological Rate vs Rhythm Control 180
Summary and Conclusions 185
References 185
Antithrombotic Treatment and Cardioversion of Patients with Atrial Fibrillation 190
Stroke Risk in Atrial Fibrillation 190
Warfarin 193
Anticoagulation for Acute Stroke 197
Bridging Antithrombotic Therapy 197
Aspirin 198
Implementation of Trial Evidence to Clinical Practice 199
The Future 201
References 201
Current Role of Medical Therapy for Prevention or Termination of Atrial Fibrillation 206
Antiarrhythmic Drugs to Prevent Atrial Fibrillation 207
Currently Available Agents for Long-Term Use 207
Adverse Effects of Antiarrhythmic Drugs 208
Inhibition of the Renin–Angiotensin System for the Prevention of Atrial Fibrillation 209
Pharmacological Cardioversion 210
The Pill-in-the-Pocket Concept 211
Newer Agents 212
Conclusions 213
References 213
Atrial Fibrillation Ablation 218
Applied Cardiac Anatomy for Catheter Ablation of Atrial Fibrillation 220
Introduction 220
Anatomy of the Atrial Septum and Transseptal Catheterization 220
Anatomy of the Atria and the Pulmonary Veins 224
Anatomy of the Major Structures Surrounding the Heart 225
Conclusion 227
References 227
Selection of Ablation Catheters, Energy Sources, and Power Delivery 230
Introduction 230
Evolution of Technology 232
Radio-Frequency Ablation 232
Cryoablation 235
High-Intensity Focused Ultrasound 237
Other Energy Sources and Approaches for Lesion Formation 238
References 240
Anatomically Guided Catheter Ablation for Atrial Fibrillation 244
Mechanistic Background 244
Clinical Applications 246
Conclusions 252
References 252
Chronic Atrial Fibrillation and Catheter Ablation 258
Introduction 259
Techniques and Strategies for Chronic Atrial Fibrillation Ablation 259
Conclusion 264
References 264
Hybrid Strategies for Ablation of Permanent AF 266
Adjunctive Strategies to Improve Long-Term Outcome of Atrial Fibrillation Ablation 267
Clinical Implications 272
References 273
Isolation of Pulmonary Vein Antrum Triggers 276
Introduction 276
Pathophysiology of the Pulmonary Veins in the Triggering and Maintenance of Atrial Fibrillation 277
Anatomy of the Pulmonary Vein Antrum 278
Evolution in the Technique of Pulmonary Vein Isolation 280
Pulmonary Vein Antrum Isolation Technique 281
Efficacy of Pulmonary Vein Antrum Isolation 288
Relationship of Recurrence to Pulmonary Vein–Left Atrium Reconnection 290
Conclusions 290
References 291
Complications and Definition of Success 296
Complications 296
Definitions of Success for Atrial Fibrillation Ablation 302
References 304
Strategies on How to Diagnose, Prevent, and Treat Pulmonary Vein Stenosis 312
Introduction 313
Pulmonary Vein Injury 313
Diagnosis and Pulmonary Vein Stenosis 314
Interventional Approach to Pulmonary Vein Stenosis 318
Asymptomatic Stenosis 322
Risk of Intervention for Pulmonary Vein Stenosis 323
Conclusion 323
References 323
Surgery for Atrial Fibrillation 328
Ablation of Atrial Fibrillation with Cardiac Surgery 330
Introduction 330
Rationale for Surgical Ablation 331
The Maze Procedure 333
New Approaches to Surgical Ablation of Atrial Fibrillation 335
The Left Atrial Appendage 338
Challenges and Future Directions 339
Conclusions 340
References 340
Epicardial Atrial Fibrillation Ablation 344
Introduction 344
Concepts Behind Epicardial Approach to Atrial Fibrillation Ablation 345
Experimental Studies 347
Early Clinical Results 348
Limitations to Epicardial Approach 349
Future Directions 350
References 351
Introduction 354
Minimally Invasive Surgical Treatment of Atrial Fibrillation 354
Minimally Invasive Epicardial Ablation 354
References 359
Imaging, Technologies, and Associated Arrhythmias 360
CT and MR Images in Atrial Fibrillation 362
Introduction 362
Anatomic Characteristics of Pulmonary Veins 363
Anatomic Relationship Between the Left Atrium, Esophagus, and Adjacent Vascular Structures 364
Morphological Remodeling of Pulmonary Veins and Left Atrium in Patients with Atrial Fibrillation 365
Detection of Complications After Catheter Ablation 366
Conclusion 366
References 366
Integrative Approaches to Imaging 370
Fluoroscopy 371
Computed Tomography 372
Magnetic Resonance Imaging 376
Intracardiac Echocardiography 376
Nonfluoroscopic Three-Dimensional Catheter Navigation and Mapping 378
Image Integration 379
Conclusions 380
References 380
Novel Balloon Catheter Technologies for Pulmonary Vein/ Antrum Isolation 384
High-Intensity Focused Ultrasound Balloon Catheter 385
Endoscopic Laser Balloon Catheter 395
Cryothermal Balloon Catheter 400
Summary 402
References 402
Remote Catheter Navigation 406
Background 406
Remote Magnetic Navigation 407
Remote Robotic Navigation 412
Conclusion 416
References 416
Insight into the Pathophysiology of Atrial Flutter and Its Relationship to Atrial Fibrillation 418
Introduction 418
Spontaneous Conversion 419
As a Result of Medications 419
As a Result of Ablation or Surgery 419
Common Triggers 420
Conclusion 420
References 420
Ablation Strategies for Left Atrial Flutter 422
Introduction 422
Definition of Left Atrial Flutter 423
Incidence 423
Identification of Left Atrial Flutter 425
Mechanisms of Left Atrial Flutter Postprocedure 426
Management /Approach to the Patient with Suspected Left Atrial Flutter 428
Ablative Procedure for Post-Atrial Flutter Ablation Tachycardias 429
Prognosis 435
Complications 436
Conclusion 437
References 437
Ablation Strategies for Left Atrial Flutter 440
Case 1 440
Case 2 444
Future Directions in Atrial Fibrillation 448
Atrial Fibrillation: Future Directions 450
Better Understanding the Mechanism of Atrial Fibrillation 451
Rhythm Control of Atrial Fibrillation 453
Rate Control of Atrial Fibrillation ( Drugs and Implantable Devices) 459
Prevention of Thromboembolism 460
Conclusion 460
References 461
Index 466