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While CTI-dependent AFL is the most common AT late after open heart surgery, atypical AFL becomes progressively more common with more extensive atriotomy. Right atrial incisional tachycardia is the dominant non-CTI-dependent AFL after opening of the RA, while a perimitral or roof-dependent LA circuit can be expected after LA operations.

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Indexed minimal LA volume is highly associated with ablation success in patients with persistent and longstanding persistent AF.

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.

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.

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. Ninety-five 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 ≤ 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 ≤ 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.

BackgroundDetection 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.MethodsWe 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.ResultsThe 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).ConclusionAccurate assessment of diastolic dysfunction in patients with persistent and longstanding persistent AF is difficult using TTE. A combination of LAVmin, PVS, and E might be helpful to determine elevated LAP.