Background Catheter ablation of atrial fibrillation is currently guided by x-ray fluoroscopy. The associated radiation risk to patients and medical staff may be significant. We report an atrial fibrillation ablation technique using intracardiac echocardiography (ICE) and electroanatomic mapping without fluoroscopy. Methods and Results Twenty-one patients with atrial fibrillation (age, 42 to 73 years; 14 male; 14 paroxysmal, 7 persistent; body mass index, 26 to 38) underwent ablation. A decapolar catheter was advanced through the left subclavian vein until stable coronary sinus electrograms appeared on all electrodes. Two 9F sheaths were advanced transfemorally over a guide wire to the right atrium. A rotational ICE catheter was advanced through a deflectable sheath. Double transseptal puncture was performed with ICE guidance and facilitated by electrocautery. A 3D MRI left atrial image was registered to the ostia of the pulmonary veins using ICE. Catheter ablation was performed using ICE and electroanatomic mapping navigation. In 19 cases, no fluoroscopy was used and the staff did not wear protective lead. In 2 cases, 2 to 16 minutes of fluoroscopy was used to assist transseptal puncture. Median procedure time was 208 (188 to 221) minutes; coronary sinus cannulation took 5 (2 to 26) minutes; double transseptal took 26 (17 to 40) minutes; left atrial ablation time was 103 (90 to 127) minutes. All patients underwent circumferential pulmonary vein ablation and 8 patients underwent additional left atrial ablation. There were no procedure-related complications. Conclusions Catheter ablation of atrial fibrillation without fluoroscopy is feasible and merits further attention. This technique may be especially helpful in preventing x-ray exposure in children, pregnant women, and obese patients undergoing left atrial ablation.

Objectives Using cardiac magnetic resonance (CMR), we sought to evaluate the relative influences of mechanical, electrical, and scar properties at the left ventricular (LV) lead position (LVLP) on CRT response and clinical events. Background CMR cine displacement encoding with stimulated echoes (DENSE) provides high quality strain for overall dyssynchrony (circumferential uniformity ratio estimate [CURE, 0–1]) and timing of onset of circumferential contraction at the LVLP. CMR DENSE, late gadolinium enhancement, and electrical timing together could improve upon other imaging modalities for evaluating the optimal LVLP. Methods Patients had complete CMR studies and echocardiography before CRT. CRT response was defined as a 15% reduction in LV end-systolic volume. Electrical activation was assessed as the time from QRS-onset-to-LVLP-electrogram (QLV). Patients were then followed for clinical events. Results In 75 patients, multivariable logistic modeling accurately identified the 40 (53%) of patients with CRT response (AUC=0.95 [p<0.0001]) based on CURE (OR 2.59/0.1 decrease), delayed circumferential contraction onset at LVLP (OR 6.55), absent LVLP scar (OR 14.9), and QLV (OR 1.31/10 ms increase). The 33% of patients with CURE<0.70, absence of LVLP scar, and delayed LVLP contraction onset had a 100% response rate, whereas those with CURE≥0.70 had a 0% CRT response rate and a 12-fold increased risk of death, and the remaining patients had a mixed response profile. Conclusions Mechanical, electrical, and scar properties at the LVLP together with CMR mechanical dyssynchrony are strongly associated with echocardiographic CRT response and clinical events after CRT. Modeling these findings holds promise for improving CRT outcomes.

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BACKGROUND The Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke (CHADS2) score is used to predict the need for oral anticoagulation for stroke prophylaxis in patients with atrial fibrillation. The Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65–74 years, Sex category (CHA2DS2-VASc) schema has been proposed as an improvement. Our objective is to determine how adoption of the CHA2DS2-VASc score alters anticoagulation recommendations. METHODS Between 2004 and 2008, 1664 patients were seen at the University of Virginia Atrial Fibrillation Center. We calculated the CHADS2 and CHA2DS2-VASc scores for each patient. The 2006 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines for atrial fibrillation management were used to determine anticoagulation recommendations based on the CHADS2 score, and the 2010 European Society of Cardiology guidelines were used to determine anticoagulation recommendations based on the CHA2DS2-VASc score. RESULTS The average age was 62 ± 13 years, and 34% were women. Average CHADS2 and CHA2DS2-VASc scores were 1.1 ± 1.1 and 1.8 ± 1.5, respectively (P < .0001). The CHADS2 score classified 33% as requiring oral anticoagulation. The CHA2DS2-VASc score classified 53% as requiring oral anticoagulation. For women, 31% had a CHADS2 score ≥ 2, but 81% had a CHA2DS2-VASc score ≥ 2 (P = .0001). Also, 32% of women with a CHADS2 score of zero had a CHA2DS2-VASc score ≥ 2. For men, 25% had a CHADS2 score ≥ 2, but 39% had a CHA2DS2-VASc score ≥ 2 (P < .0001). CONCLUSION Compared with the CHADS2 score, the CHA2DS2-VASc score more clearly defines anticoagulation recommendations. Many patients, particularly older women, are redistributed from the low- to high-risk categories.

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