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Articles by A. Natale
Total Records ( 5 ) for A. Natale
  L Di Biase , J. D Burkhardt , P Mohanty , J Sanchez , S Mohanty , R Horton , G. J Gallinghouse , S. M Bailey , J. D Zagrodzky , P Santangeli , S Hao , R Hongo , S Beheiry , S Themistoclakis , A Bonso , A Rossillo , A Corrado , A Raviele , A Al Ahmad , P Wang , J. E Cummings , R. A Schweikert , G Pelargonio , A Dello Russo , M Casella , P Santarelli , W. R Lewis and A. Natale
 

Background— Together with pulmonary veins, many extrapulmonary vein areas may be the source of initiation and maintenance of atrial fibrillation. The left atrial appendage (LAA) is an underestimated site of initiation of atrial fibrillation. Here, we report the prevalence of triggers from the LAA and the best strategy for successful ablation.

Methods and Results— Nine hundred eighty-seven consecutive patients (29% paroxysmal, 71% nonparoxysmal) undergoing redo catheter ablation for atrial fibrillation were enrolled. Two hundred sixty-six patients (27%) showed firing from the LAA and became the study population. In 86 of 987 patients (8.7%; 5 paroxysmal, 81 nonparoxysmal), the LAA was found to be the only source of arrhythmia with no pulmonary veins or other extrapulmonary vein site reconnection. Ablation was performed either with focal lesion (n=56; group 2) or to achieve LAA isolation by placement of the circular catheter at the ostium of the LAA guided by intracardiac echocardiography (167 patients; group 3). In the remaining patients, LAA firing was not ablated (n=43; group 1). At the 12±3-month follow-up, 32 patients (74%) in group 1 had recurrence compared with 38 (68%) in group 2 and 25 (15%) in group 3 (P<0.001).

Conclusions— The LAA appears to be responsible for arrhythmias in 27% of patients presenting for repeat procedures. Isolation of the LAA could achieve freedom from atrial fibrillation in patients presenting for a repeat procedure when arrhythmias initiating from this structure are demonstrated.

  L Di Biase , L. C Saenz , D. J Burkhardt , M Vacca , C. S Elayi , C. D Barrett , R Horton , R Bai , A Siu , T. S Fahmy , D Patel , L Armaganijan , C. T Wu , S Kai , C. K Ching , K Phillips , R. A Schweikert , J. E Cummings , M Arruda , W. I Saliba , M Dodig and A. Natale
 

Background— Left atrioesophageal fistula is a rare but devastating complication that may occur after catheter ablation of atrial fibrillation. We used capsule endoscopy to assess esophageal injury after catheter ablation for atrial fibrillation in a population randomized to undergo general anesthesia or conscious sedation.

Methods and Results— Fifty patients undergoing atrial fibrillation ablation for paroxysmal symptomatic atrial fibrillation refractory to antiarrhythmic drugs were enrolled and randomized, including those undergoing the procedure under general anesthesia (25 patients, group 1) and those receiving conscious sedation with fentanyl or midazolam (25 patients, group 2). All patients underwent esophageal temperature monitoring during the procedure. The day after ablation, all patients had capsule endoscopy to assess the presence of endoluminal tissue damage of the esophagus. We observed esophageal tissue damage in 12 (48%) patients of group 1 and 1 esophageal tissue damage in a single patient (4%) of group 2 (P<0.001). The maximal esophageal temperature was significantly higher in patients undergoing general anesthesia (group 1) versus patients undergoing conscious sedation (group 2) (40.6±1°C versus 39.6±0.8°C; P< 0.003). The time to peak temperature was 9±7 seconds in group 1 and 21±9 seconds in group 2, and this difference was statistically significant (P<0.001). No complication occurred during or after the administration of the pill cam or during the procedures. All esophageal lesions normalized at the 2-month repeat endoscopic examination.

Conclusion— The use of general anesthesia increases the risk of esophageal damage detected by capsule endoscopy.

  L Di Biase , C. S Elayi , T. S Fahmy , D. O Martin , C. K Ching , C Barrett , R Bai , D Patel , Y Khaykin , R Hongo , S Hao , S Beheiry , G Pelargonio , A. D Russo , M Casella , P Santarelli , D Potenza , R Fanelli , R Massaro , P Wang , A Al Ahmad , M Arruda , S Themistoclakis , A Bonso , A Rossillo , A Raviele , R. A Schweikert , D. J Burkhardt and A. Natale
 

Background— Whether different ablation strategies affect paroxysmal atrial fibrillation (AF) long-term freedom from AF/atrial tachyarrhythmia is unclear. We sought to compare the effect of 3 different ablation approaches on the long-term success in patients with paroxysmal AF.

Methods and Results— One hundred three consecutive patients with paroxysmal AF scheduled for ablation and presenting in the electrophysiology laboratory in AF were selected for this study. Patients were randomized to pulmonary vein antrum isolation (PVAI; n=35) versus biatrial ablation of the complex fractionated atrial electrograms (CFAEs; n=34) versus PVAI followed by CFAEs (n=34). Patients were given event recorders and followed up at 3, 6, 9, 12, and 15 months postablation. There was no statistical significant difference between the groups in term of sex, age, AF duration, left atrial size, and ejection fraction. At 1 year follow-up, freedom from AF/atrial tachyarrhythmia was documented in 89% of patients in the PVAI group, 91% in the PVAI plus CFAEs group, and 23% in the CFAEs group (P<0.001) after a single procedure and with antiarrhythmic drugs.

Conclusion— No difference in terms of success rate was seen between PVAI alone and PVAI associated with defragmentation. CFAEs ablation alone had the smallest impact on AF recurrences at 1-year follow-up. These results suggest that antral isolation is sufficient to treat most patients with paroxysmal AF.

  Y Khaykin , A Skanes , J Champagne , S Themistoclakis , L Gula , A Rossillo , A Bonso , A Raviele , C. A Morillo , A Verma , Z Wulffhart , D. O Martin and A. Natale
 

Background— The study was conducted to compare relative safety and efficacy of pulmonary vein antrum isolation (PVAI) using intracardiac echocardiographic guidance and circumferential pulmonary vein ablation (CPVA) for atrial fibrillation (AF) using radiofrequency energy.

Methods and Results— Sixty patients (81% men; 81% paroxysmal; age, 56±8 years) failing 2±1 antiarrhythmic drugs were randomly assigned to undergo CPVA (n=30) or PVAI (n=30) at 5 centers between December 2004 and October 2007. CPVA patients had circular lesions placed at least 1 cm outside of the veins. Ipsilateral veins were ablated en block with the end point of disappearance of potentials within the circular lesion. Left atrial roof line and mitral isthmus line were ablated without verification of block. For patients in AF postablation or with AF induced with programmed stimulation, complex fractionated electrograms were mapped and ablated to the end point of AF termination or disappearance of complex fractionated electrograms. PVAI did not include complex fractionated electrogram ablation. Esophageal temperature was monitored and kept within 2°C of baseline or under 39°C. Success was defined as absence of atrial tachyarrhythmias (AF/AT) off antiarrhythmic drugs. There was no difference between CPVA and PVAI regarding to baseline variables, catheter used, duration of the procedure, or RF delivery. Fluoroscopy time was longer with PVAI (54±17 minutes versus 77±18 minutes, P=0.0001). No significant complications occurred in either arm. PVAI was more likely to achieve control of AF/AT off antiarrhythmic drugs (57% versus 27%, P=0.02) at 2±1 years of follow-up.

Conclusions— A single PVAI procedure is more likely to result in freedom from AF/AT off antiarrhythmic drugs than CPVA supplemented by complex fractionated electrogram ablation in select patients.

  D Patel , P Mohanty , L Di Biase , M Shaheen , W. R Lewis , K Quan , J. E Cummings , P Wang , A Al Ahmad , P Venkatraman , E Nashawati , D Lakkireddy , R Schweikert , R Horton , J Sanchez , J Gallinghouse , S Hao , S Beheiry , D. S Cardinal , J Zagrodzky , R Canby , S Bailey , J. D Burkhardt and A. Natale
  Background—

Obstructive sleep apnea (OSA) may be associated with pulmonary vein antrum isolation (PVAI) failure. The aim of the present study was to investigate if treatment with continuous positive airway pressure (CPAP) improved PVAI success rates.

Methods and Results—

From January 2004 to December 2007, 3000 consecutive patients underwent PVAI. Patients were screened for OSA and CPAP use. Six hundred forty (21.3%) patients had OSA. Patients with OSA had more procedural failures (P=0.024) and hematomas (P<0.001). Eight percent of the non-OSA paroxysmal atrial fibrillation patients had nonpulmonary vein antrum triggers (non-PV triggers) and posterior wall firing versus 20% of the OSA group (P<0.001). Nineteen percent of the non-OSA nonparoxysmal atrial fibrillation population had non-PV triggers versus 31% in the OSA group (P=0.001). At the end of the follow-up period (32±14 months), 79% of the non-CPAP and 68% of the CPAP group were free of atrial fibrillation (P=0.003). Not using CPAP in addition to having non-PV triggers strongly predicted procedural failure (hazard ratio, 8.81; P<0.001).

Conclusions—

OSA was an independent predictor for PVAI failure. Treatment with CPAP improved PVAI success rates. Patients not treated with CPAP in addition to having higher prevalence of non-PV triggers were 8 times more likely to fail the procedure.

 
 
 
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