| Part One:The study on the anatomical morphology of left atrium and pulmonary veins in patients with non-valvular atrial fibrillationObjective:To investigate the anatomical morphology changes of left atrium and pulmonary veins in patients with non-valvular atrial fibrillation (AF), and its relationship with outcome of radiofrequency catheter ablation (RFCA).Methods:One hundred thirty six patients with non-valvular AF were enrolled in the study. All the patients received the echocardiography and the magnetic resonance angiography or the multidetector-row computed tomography of left atrium (LA) and pulmonary veins (PVs). The anatomical images acquired by MRI or MDCT were merged with the electroanatomical images acquired by CARTO XP with the CartoMerge technique during procedures to delineate the real anatomical bounds between LA and PVs. The variations of PVs derangements to LA were analyzed by six standard projections (anterior-posterior, posterior-anterior, left-anterior-oblique, right-anterior-oblique, left-lateral, and right-lateral). The three-dimensional (anterior-posterior, superior-inferior and left-right) left atrium diameters (LADs) were measured on the horizontal, sagittal and coronal planes, respectively. AF recurrence was defined as documented episode of AF or atrial flutter or atrial tachycardia lasting for?30s on 24 h-Holter or transtelephonic electrocardiograms during follow-up after three months.Results:The three-dimension LADs measured by CartoMerge technique were lineally related with those measured by echocardiography. The anterior-posterior LAD measured by CartoMerge technique was positively related with that measured by echocardiography, and was larger by 7.4±3.6mm. The three-dimension LADs were larger in the patients with persistent AF than that in patients with paroxysmal AF, whatever on the anterior-posterior LAD (46.7±6.6mm vs 42.5±6.8mm,p=0.0007),the superior-inferior LAD (58.2±7.3mm vs 53.3±8.4mm, P=0.0009), and the left-right LAD(71.8±9.8mm vs 63.2±9.4mm, P<0.0001). The anterior-posterior LAD in male was larger than that in female (56.2±8.9 vs 52.6±6.5mm, P=0.0219). The anterior-posterior LAD in patients with hypertension were larger than that without hypertension (46.2±7.3mm vs 42.0±6.1mm, P=0.0003). The success rate of ablation for AF was 61.3%during the follow up of median 20(4 to 58) months. The LAD, and were larger in AF recurrence group compared with the non recurrence group whatever on the anterior-posterior LAD(47.0±7.6mm vs 42.1±5.9mm, P <0.0001), the superior-inferior LAD(57.2±9.2mm vs 53.8±7.5mm, P=0.0191) and the left-right LAD(68.6±10.4mm vs 64.8±10.1mm, P=0.0372). The success rate was negatively related with LAD. The success rates were 76%,76%,56%,48%,30%when a grade of 5mm increase was set on LAD measured by echocardiography. The success rates were 68%, 71%,68%,48%,33%when the grading of 5mm was set on the superior-inferior LAD from 45mm to 65mm. The success rates were 90%,72%,68%,45%,37%when the grading of 5mm was set on the anterior-posterior LAD from 30mm to 50mm. The success rates were 86%,67%,65%,46%,33%when the grading of 10mm was set on the left-right LAD from 40mm to 80mm. Ninety-two patients (67.7%) presented typical PV branching pattern (left/right superior/inferior PVs). Twenty-four patients (32.3%) presented atypical PV branching pattern. In most circumstance, the PV morphology variations showed left common trunk (17.7%/24) or right multi-PV (15.4%/21) including right 3-PVs (11.0%/15) and 4-PVs (4.4%/6). There was no significant difference on variation of PVs between the patients with paroxysmal AF and persistent AF. The patients with right 3-PVs had a higher AF recurrence (18.9%vs 6.9%, p=0.0404). The mean PVs diameters were 16.5±3.6mm, the mean maximum PV diameter was 18.8±4.0mm, the mean minimum PV diameter was 14.2±3.8mm, the mean PV ovality was 0.25±0.14. The mean diameters of superior PVs were larger than that of the inferior PVs, whatever in left PVs (17.4±3.3mm vs 13.8±2.3mm, P<0.01) and in right PVs (19.0±3.6mm vs 16.0±3.0mm, P<0.0001). The mean diameters of left PVs were larger than that of the right PVs, whatever in left superior PVs (P< 0.0001) and in inferior PVs (P< 0.0001). The mean diameter of left PVs and right superior PVs in patients with persistent AF were larger than that in patients with paroxysmal AF(P<0.01 for all). The mean superior PVs diameter in patients with male were larger than that in patients with female (p<0.01 for all). The PVs diameter were positively correlated with the three-dimension LAD (P<0.01). There was no significant difference on PVs diameter between the patients with AF recurrence and the non-recurrence patients.Conclusions:The three-dimension LAD measured by CartoMerge was well correlated with LAD measured by echocardiography, especially for the anterior-posterior LAD. Sex, AF type, and hypertension were the influence factors of LAD. The success rate of ablation for patients with AF decreased with the LAD enlarged. Variation of PVs was a common phenomenon and showed left PVs common trunk and right multi-PVs in mostly circumstance. Most PVs diameters were between 15mm to 24mm, however, its variation were larger. The diameters of superior PVs were larger than that of the inferior PVs. Sex and LAD, not hypertension and diabetes mellitus, were the influence factors of PVs diameters. There was no significant difference on PVs diameters between the AF-recurrence patients and the non-recurrence patients. These data indicated the PVs enlargement was secondary to LAD expansion.Part Two:High-sensitive C-reactive protein and atrial fibrillation recurrence after radiofrequency catheter ablationAim:To investigated the relationship between the plasma high-sensitive C-reactive protein (hsCRP) concentrations before radiofrequency catheter ablation (RFCA) and atrial fibrillation (AF) recurrence during follow up.Methods:One hundred eighty four patients without structural heart disease who underwent first-time RFCA were included in the study (paroxysmal/persistent AF:118/66). Left atrial diameter was measured by trans-esophageal echocardiography. Plasma hsCRP concentration was determined by enzyme-linked immunosorbent assay before RFCA. Based on the follow-up outcomes, patients were divided into two groups, a recurrence group, and a non-recurrence group. AF recurrence was defined as AF or atrial flutter or atrial tachycardia episodes lasting for?30s during regular follow-up (>12 months).Results:Sixty three (34.2%) patients [paroxysmal/persistent AF:37(31.4%)/26(39.4%)] had AF recurrence during follow-up of mean 18(range from 5 to 44) months. The plasma hsCRP concentration in the recurrence group was significantly higher than that in the non-recurrence group for all patients [1.90(0.20,5.53) mg·L-1 vs 1.02(0.13,4.20) mg·L P= 0.0007], for patients with paroxysmal AF [1.75 (0.20,8.62) mg·L-1 vs 0.99 (0.10,3.40) mg·L-1, P=0.0113], and for those with persistent AF [2.07 (0.10,5.52) mg·L-1 vs 1.01 (0.15, 5.06) mg·L-1, P=0.0498]. Multiple logistic regression analyses showed that the higher level of the plasma hsCRP (OR:3.00 (95%CI:1.56 to 5.75), P=0.0009] was a significant prognostic predictor of AF recurrence, both for patients with paroxysmal AF [OR:2.39 (95%CI:1.08 to 5.31), P=0.0325] and those with persistent AF [OR:4.09 (95%CI:3.25 to 13.4), P=0.0201)].Conclusion:Plasma hsCRP concentration before RFCA was associated with AF recurrence after first-time RFCA procedure for both paroxysmal and persistent AF patients. Plasma hsCRP concentration could play a role in prediction of AF recurrence after first-time RFCA procedure. Objective:To investigate the influence of different manner of retain to sinus rhythm (SR) during procedures on outcomes of radiofrequency catheter ablation (RFCA) for patients with persistent atrial fibrillation (PerAF).Methods:Seventy one patients with PerAF who received RFCA were included in the study. RFCA procedure included following:first, circumferential pulmonary vein isolation around ipsilateral pulmonary vein; second, linear ablation in the roof and the mitral isthmus of the left atrium; third, mitral annular ablation in the inferior left atrium along the mitral annulus; finally, ablation of complex fractionated electrograms in its common locations such as septum and anterior wall of left atrium. During the procedure, drug (propafenone and/or ibutilide) and/or electrical conversion (EC) were used if AF did not terminated after the scheduled ablation was completed. AF recurrence was defined as documented episode of AF or atrial flutter or atrial tachycardia lasting for> 30s on 24h-Holter or electrocardiogram or trans-telephonic electrocardiogram during follow-up after three months. The seven patients with recurrent AF received re-ablation (5 patients with 2 procedures and 2 patients with 3 procedures).Results:During total 82 procedures, the patients recovered to SR by RFCA directly in 19 (23.2%) procedures, or by drug or/and electrical conversion in 56 (68.3%) procedures. During the follow-up of mean 24(4 to 62) months, the success rate was 52.1%(37/71) after first-time ablation and was 59.2%after mean 1.2 time ablations. The success-rates were same whether recovering SR by RFCA or by drug or/and EC [57.9%(11/19) vs 51.8%(29/56), P=0.67]. The success rates for patients attained SR during procedure were higher than that for patients unattained SR [53.3%(40/75) vs 28.6%(2/7), P=0.26]. Multiple logistic regression analyses showed that the left atrial diameter was a significant prognostic predictor of AF recurrence[odds ratio(OR):0.873,95%confidence interval(CI): 0.792-0.961, P=0.0056].Conclusions:Recovering to SR by ablation was an unnecessary endpoint of RFCA for PerAF. However, recovering to SR by drug or/and EC after ablation can improve the outcomes of RFCA for PerAF. |
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