Luận án về vĩnh viễn nhịp tim bất thường - Nghiên cứu tại 108 Viện Khoa học Y học và Dược học

MINISTRY MINISTRY OF EDUCATION AND TRAINING OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES BY VIEN HOANG LONG MD CLINICAL, PARACLINICAL CHARACTERISTICS, ELECTROPHYSIOLOGICAL FEATURES AND RESULT OF PERSISTENT ATRIAL FIBRILLATION ABLATION WITH RADIOFREQUENCY ENERGY A Dissertation for the Degree of Medical Doctor of Cardiology HA NOI - 2023 MINISTRY MINISTRY OF EDUCATION AND TRAINING OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES BY VIEN HOANG LONG MD CLINICAL, PARACLINICAL CHARACTERISTICS, ELECTROPHYSIOLOGICAL FEATURES AND RESULT OF PERSISTENT ATRIAL FIBRILLATION ABLATION WITH RADIOFREQUENCY ENERGY A Dissertation for the Degree of Medical Doctor of Cardiology Speciality: Internal Medicine/Internal Cardiology Code: 9720107 HA NOI - 2023 ACKNOWLEDGMENTS For the completion of this dissertation, my deepest appreciations go to: - 108 Institute of clinical medical and pharmaceutical sciences - Department of Post graduates of 108 Central Military Hospital - Department of Internal Cardiological Medicine - Board of Director of Vietnam National Heart Institute - Bach Mai Hospital - C7 Department, Cardiac catheterization laboratory Department, Out- patients service Department, Electrography and Electrophysiology Department of Vietnam National Heart Institute - Bach Mai Hospital Special thanks to: - My dearest teachers: Associate Professor Pham Quoc Khanh and Associate Professor Pham Nguyen Son - Pham Tran Linh, PhD - Phan Dinh Phong, PhD - Dr. Le Vo Kien, Dr. Tran Tuan Viet, Dr. Nguyen Thi Le Thuy, Dr.

Nguyen Duy Linh, Dr. Nguyen Duy Tuan I am personally indebted to: - My past grandparents Vien Van Doan, Nguyen Thi Bi, my beloved parents Vien Van Doan, Nguyen Thi Kim Hoang for giving my birth, my wife Le Thanh Ha, my kids Hoang Bach and Nhat Quang for their love to me - My patients, my staff without them this work would never be completed PROTESTATION I hereby declare that this is my own research, under the guidance of Assoc. Pham Quoc Khanh and Assoc. Pham Nguyen Son.

All data in this dissertation were collected by myself, and the results presented are honest and have not been published in any other research work in Vietnam. I ensure the honesty of the data and the results obtained from data processing in this study. Hanoi, 26th June 2023 Author of the dissertation Vien Hoang Long LIST OF ABBREVIATIONS 2D 2-dimensional ACC American College of Cardiology AFL Atrial flutter AH Atrial - his AHRE Atrial high-rate episode APHRS Asia Pacific Heart Rhythm Society AT Atrial tachycardia AVN Atrioventricular node BMI Body mass index BP Blood pressure bpm beats per minute CHA2DS2-VASc Stroke risk score CHA2DS2-VASc DBP Diastolic blood pressure ECAS European Cardiac Arrhythmia Society ECG Electrocardiogram EHRA European Heart Rhythm Association ERP Effective refractory period ESC European Society of Cardiology FU Follow-up GMR Grade of mitral valve regurgitation GTR Grade of tricuspid valve regurgitation HASBLED Bleeding risk score HASBLED HCM Hypertrophic cardiomyopathy HRS Heart Rhythm Society HV His - ventricular interval LA Left atrial LIPV Left inferior pulmonary vein LSPV Left superior pulmonary vein LVZ Low voltage zone PA P - atrial interval PAC Premature atrial complex PV Pulmonary vein PVC Premature ventricular complex PVI Pulmonary vein isolation RIPV Right inferior pulmonary vein RSPV Right superior pulmonary vein SBP Systolic blood pressure SNRT Sinus node recovery time SNRTc Corrected sinus node recovery time SOLAECE Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología TABLE OF CONTENTS INTRODUCTION. Diagnosis of atrial fibrillation.

Definition of atrial fibrillation. Diagnostic criteria for atrial fibrillation. Classification of AF. Atrial fibrillation management.

Indications for atrial fibrillation catheter ablation. Recent studies about atrial fibrillation catheter ablation. Overview of study about atrial fibrillation in Vietnam. Overview of studies about persistent atrial fibrillation ablation.

SUBJECTS AND METHODS. Diagnostic criteria used in the study. Design and sample size. Study data analysis.

General characteristics of the study group. Age and sex distribution. Clinical, paraclinical characteristics and electrophysiological features. Electrophysiological features of persistent atrial fibrillation patients.

Results of catheter ablation for persistent atrial fibrillation. Technique index in catheter ablation for persistent atrial fibrillation. Result within 24 hours after catheter ablation. Results at 1 month follow-up.

Results after 3 months follow-up. Results after 6-month follow-up. The proportion of maintaining sinus rhythm and clinical and paraclinical changes after intervention. Evaluation of some factors related to the success rate of maintaining sinus rhythm after persistent atrial fibrillation ablation.

Complications of persistent atrial fibrillation catheter ablation. General characteristics of patients in the study. Clinical and paraclinical characteristics of patients in the study. Electrophysiological features of patients in study.

Results of persistent atrial fibrillation catheter ablation. Strategy and technique of persistent atrial fibrillation catheter ablation. AF-free rate after catheter ablation for persistent AF. Some factors affecting the success rate after catheter ablation for persistent AF.

Safety of persistent atrial fibrillation catheter ablation. 87 LIST OF PUBLISHED PAPERS OF THE DISSERTATION REFERENCES SAMPLES OF MEDICAL RECORD FOR THE STUDY LIST OF TABLES Table 1.1: Definition of AF according to ESC AF guideline 2020 .2: Classification of AF .3: HRS/EHRA/ECAS/APHRS/SOLAECE indications for catheter ablation .1: European Heart Rhythm Association (EHRA) symptom scale. Sex and age subgroups distribution. Risk factors and cardiovascular diseases history.

Physical examination data. Blood test index of patients. Transthoracic cardiac echo index of patients. Left atrial volume and pulmonary veins' diameter on MSCT.

The proportion of electrical connection between the pulmonary veins and the left atrium. Acute success rate of PVI. Some other atrial arrhythmias and substrates besides AF. Basic intervals after sinus rhythm recovered.

Sinus node recovery time. SNRT by age and sex. ERP of atrial, ventricular, atrial - ventricular node. Ablation time, number of lesions, procedure's time and number of cardioversions.

24-hour Holter ECG within 24 hours after catheter ablation. Transthoracic cardiac echo after catheter ablation. Proportion of sinus rhythm maintain within 24 hour of catheter ablation on Holter ECG. 24-hour ECG at 1-month follow-up.

24-hour Holter ECG at 3-month follow-up. 24-hour Holter ECG at 6-month follow-up. Compare blood test before catheter ablation and 3 times visit. Cardiac echo index baseline and 3 times follow-up.

Risk ratio of AF recurrence after 6-month FU in patient who had AF within 24 hours after CA. Risk ratio of AF recurrence after 6-month FU in patient who had AF at 1-month FU. Risk ratio of AF recurrence after 6-month FU in patient who had AF at 3-month FU. Time from AF diagnosis to CA hazard radio of AF recurrence .2: ERP of atrial, AV node and ventricular.

Sinus node recovery time .4: Procedure time and fluoroscopy time of AF ablation .5: The rate of successful conversion during the intervention and the follow-up results .6: Early AF recurrence rate in first 3 months .7: Rate of AF free after 6-month FU after first catheter ablation. 79 LIST OF FIGURES Figure 3. EHRA scale symptoms before ablation. Ablation strategies in catheter ablation for persistent atrial fibrillation.

1-month follow-up clinical symptom based on EHRA score. 3-month follow-up clinical symptom based on EHRA score. 6-month follow-up clinical symptom based on EHRA score.9: Rate of maintaining sinus rhythm after catheter ablation for persistent atrial fibrillation. Clinical symptoms based on EHRA score of patients before ablation and each visit follow-up times.

Comparing clinical symptoms between AF recurrence and AF freedom .12: Freedom of AF between 2 groups of .13: Freedom of AF between 2 groups of LA diameter .14: Freedom AF between 2 age groups .15: Freedom of AF between 2 BMI groups.1: Combined point estimates and 95% CI for single-procedure and multiple-procedure cohorts across all six ablation approaches. 80 LIST OF PICTURES Picture 1.1: AF on 12 lead ECG.2: ESC guideline for catheter ablation of AF 2020. Evaluation of sinus node recovery time. 3D Ensite system and the locations of electrode patches.

The steerable, decapolar circular mapping catheter. The irrigated tip ablation catheter. (a) The left subclavian venous access for placement of coronary sinus electrode catheter, (b) The right femoral venous accesses for two long sheaths and the left femoral venous access for placement of right ventricular electrode catheter .8: Sheath 6F, long sheath SLO, septal puncture needle. The right ventricle is stimulated and the left atrial imaging is performed in LAO 30º view (a) and RAO 30º view (b) 3D reconstruction of the left atrium and voltage mapping.

Elimination of all the potentials in the PVs. (a) Pulmonary venous electrical signals before ablation; (b) Pulmonary venous electrical signals after ablation (Patient Huynh Cong L. The atrium is captured when pacing from the coronary sinus electrode, but no conduction into the PV (no electrical signal is recorded from the PV electrode placed inside the left superior pulmonary vein). No conduction into the left atrium when pacing from the PV1-2 electrode.

(a) Endocardial mapping of the left atrium is performed before ablation based on MSCT (b) Reconstruction of the left atrium and identification of low voltage areas after undergoing pulmonary vein isolation ablation. Basic interval measurements in sinus rhythm. Patient flow and study protocol. 28 1 INTRODUCTION Over the past 20 years, atrial fibrillation (AF) has become one of the most investigated arrhythmias and has incurred significant healthcare costs in developed countries.

Besides causing symptoms and affecting quality of life, AF is a leading cause of systemic thromboembolism, stroke, heart failure, mortality, and increased hospital readmission rate in patients with cardiovascular disease. According to the European Society of Cardiology statistics in 2016, there are approximately 43.6 million AF patients worldwide, and the incidence of AF increases with age and coexisting cardiovascular risk factors [1]. Unlike other arrhythmias, AF tends to progress from paroxysmal AF to persistent and eventually long-standing persistent AF over time. Massimo Zoni-Berisso et al.'s population-based study in Europe in 2014 reported that 50% of AF patients had long-standing persistent AF, 20-30% had paroxysmal AF, and persistent AF [2].

Early rhythm control intervention for paroxysmal and persistent AF would reduce the progression to long-standing persistent AF. Until now, there have been many advances in the management of AF with promising results. first applied radiofrequency energy to treat AF patients, but the success rate was low (33-60%), the complication rate was high, and the procedure took up to 5-6 hours. used the three-dimensional CARTO cardiac mapping system to treat AF with radiofrequency energy.

Since then, several systems such as ENSITE VELOCITY, the new-generation CARTO system have made radiofrequency ablation of AF widespread and become the most advanced approach in AF treatment with a high success rate and a low complication rate. Despite many advances and improvements in tools, techniques, and success rates in maintaining sinus rhythm after intervention for patients with 2 persistent AF, the success rate is not as high as those with paroxysmal AF. In addition, the cost of an ablation procedure for AF (especially in Vietnam) is also high. Therefore, ablation intervention for persistent AF has not been widely performed and standardised in Vietnam.

Do patients with persistent AF have different clinical, paraclinical, and electrophysiological characteristics to those with paroxysmal AF? What are the difficulties and practical effectiveness of performing ablation intervention on these patients? Research objective: For the reasons above and with the desire to apply a new method in Vietnam as well as to make this modern treatment method more widespread, we conducted the study "Clinical, paraclinical characteristics, electrophysiological features, and result of persistent atrial fibrillation ablation with radiofrequency energy". Research aimed to achieve the following two objectives: 1. To assess clinical, paraclinical characteristics and electrophysiological features of persistent atrial fibrillation patients. To evaluate results within 6-month follow-up after persistent atrial fibrillation ablation.

3 CHAPTER 1 LITERATURE OVERVIEW 1. Diagnosis of atrial fibrillation 1. Definition of atrial fibrillation Table 1.1: Definition of AF according to ESC AF guideline 2020 [3] Definition A supraventricular tachyarrhythmia with uncoordinated atrial electrical activation and consequently ineffective atrial contraction.