Catheter Ablation of Long‐Standing Persistent Atrial Fibrillation: A Lesson from Circumferential Pulmonary Vein Isolation

Tilz, Roland Richard; Chun, K.R. Julian; Schmidt, Boris; Fuernkranz, Alexander; Wißner, Erik; Koester, Ilka; Baensch, Dietmar; Boczor, Sigrid; Koektuerk, Buelent; Metzner, Andreas; Zerm, Thomas; Ernst, Sabine; Antz, Matthias; Kuck, Karl‐Heinz; Ouyang, Feifan

doi:10.1111/j.1540-8167.2010.01799.x

Cited by 100 publications

(76 citation statements)

References 47 publications

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“…Similarly, another cohort study has demonstrated that LAA electric isolation improves the clinical outcome in repeat ablation of long-standing persistent AF. 5 20 which seeks to determine whether empirical LAA isolation along with a standard ablation protocol is superior to the standard approach alone, may corroborate these findings. However, the standard anticoagulation…”

Section: Discussionsupporting

confidence: 71%

Left Atrial Appendage Electrical Isolation and Concomitant Device Occlusion to Treat Persistent Atrial Fibrillation

Panikker

Jarman

Virmani

et al. 2016

Circ: Arrhythmia and Electrophysiology

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Background— Left atrial appendage (LAA) electric isolation is reported to improve persistent atrial fibrillation (AF) ablation outcomes. However, loss of LAA mechanical function may increase thromboembolic risk. Concomitant LAA electric isolation and occlusion as part of conventional AF ablation has never been tested in humans. We therefore evaluated the feasibility, safety, and efficacy of LAA electric isolation and occlusion in patients undergoing long-standing persistent AF ablation. Methods and Results— Patients with long-standing persistent AF (age, 68±7 years; left atrium diameter, 46±3 mm; and AF duration, 25±15 months) underwent AF ablation, LAA electric isolation, and occlusion. Outcomes were compared with a balanced (1:2 ratio) control group who had AF ablation alone. Among 22 patients who underwent ablation, LAA electric isolation was possible in 20. Intraprocedural LAA reconnection occurred in 17 of 20 (85%) patients, predominantly at anterior and superior locations. All were reisolated. LAA occlusion was successful in all 20 patients. There were no major periprocedural complications. Imaging at 45 days and 9 months confirmed satisfactory device position and excluded pericardial effusion. One of twenty (5%) patients had a gap of ≥5 mm requiring anticoagulation. Nineteen of twenty (95%) patients stopped warfarin at 3 months. Without antiarrhythmic drugs, freedom from AF at 12 months after a single procedure was significantly higher in the study group (19/20, 95%) than in the control group (25/40, 63%), P =0.036. Freedom from atrial arrhythmias was demonstrated in 12 of 20 (60%) and 18 of 20 (90%) patients after 1 and ≤2 procedures (mean, 1.3), respectively. Conclusions— Persistent AF ablation, LAA electric isolation, and mechanical occlusion can be performed concomitantly. This technique may improve the success of persistent AF ablation while obviating the need for chronic anticoagulation. Clinical Trial Registration— URL: https://clinicaltrials.gov . Unique identifier: NCT02028130.

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Section: Discussionsupporting

confidence: 71%

Left Atrial Appendage Electrical Isolation and Concomitant Device Occlusion to Treat Persistent Atrial Fibrillation

Panikker

Jarman

Virmani

et al. 2016

Circ: Arrhythmia and Electrophysiology

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“…The role of PV is further supported by the evidence that a substantial proportion of patients can achieve stable long-term sinus rhythm off-AAD after PVI only even in longstanding persistent AF. 11,12 The challenge however remains to identify during ongoing AF that subgroup of patients with persistent AF where PVs play a major role. Previous studies including mostly patients with paroxysmal AF have shown that intermittent rapid PV activities during sustained AF were recorded from the same PVs that exhibited arrhythmogenic foci that triggered AF during sinus rhythm.…”

Section: Markers and Role Of Pv Activity In Persistent Afmentioning

confidence: 99%

Pulmonary Veins to Left Atrium Cycle Length Gradient Predicts Procedural and Clinical Outcomes of Persistent Atrial Fibrillation Ablation

Pascale

Roten

Scherr

et al. 2014

Circ: Arrhythmia and Electrophysiology

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Background-Rapid pulmonary vein (PV) activity has been shown to maintain paroxysmal atrial fibrillation (AF). We evaluated in persistent AF the cycle length (CL) gradient between PVs and the left atrium (LA) in an attempt to identify the subset of patients where PVs play an important role. Methods and Results-Ninety-seven consecutive patients undergoing first ablation for persistent AF were studied. For each PV, the CL of the fastest activation was assessed over 1 minute (PV fast ) using Lasso recordings. The PV to LA CL gradient was quantified by the ratio of PV fast to LA appendage (LAA) AF CL. Stepwise ablation terminated AF in 73 patients (75%). In the AF termination group, the PV fast CL was much shorter than the LAA CL resulting in lower PV fast /LAA ratios compared with the nontermination group (71±10% versus 92±7%; P<0.001). Within the termination group, PV fast / LAA ratios were notably lower if AF terminated after PV isolation or limited adjunctive substrate ablation compared with patients who required moderate or extensive ablation (63±6% versus 75±8%; P<0.001). PV fast /LAA ratio <69% predicted AF termination after PV isolation or limited substrate ablation with 74% positive predictive value and 95% negative predictive value. After a mean follow-up of 29±17 months, freedom from arrhythmia recurrence off-antiarrhythmic drugs was achieved in most patients with PV fast /LAA ratios <69% as opposed to the remaining population (80% versus 43%; P<0.001). Conclusions-The PV to LA CL gradient may identify the subset of patients in whom persistent AF is likely to terminate after PV isolation or limited substrate ablation and better long-term outcomes are achieved. (Circ Arrhythm Electrophysiol. 2014;7:473-482.)

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“…28, 29 In others elimination of extra PV triggers, ganglionated plexi and rotors is desirable. Because many ganglionated plexi and rotors are located in close proximity to the antral PV region large IASAs would be preferable in the treatment of persistent AF.…”

Section: Lesion Location and Differences In Iasamentioning

confidence: 99%

What Is the Acute Antral Lesion Size After Pulmonary Vein Isolation Using Different Balloon Ablation Technologies?

Perrotta

Konstantinou

Bordignon

et al. 2017

Circ J

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Background: Clinical outcome after pulmonary vein isolation (PVI) may be linked to both durability of PVI and the antral lesion size. Data on balloon-guided technologies are scarce. We investigated the size of the isolated surface area (ISA) acutely after PVI achieved by cryoballoon (CB) or laser balloon (LB), both using voltage mapping. Methods and Results:In 40 patients (73% male, mean age 66±9 years), a bipolar voltage map before and after PVI in sinus rhythm was acquired to delineate the isolated antral surface area (IASA, contiguous area of low voltage <0.5 mV) and the ISA (relative size of the low-voltage area in relation to the whole antral surface area including the posterior wall). IASA (CB: 57±14 cm 2 vs. LB: 42±15 cm 2 ; P=0.002) as well as ISA (65±8% vs. 54±10%; P=0.001) were significantly larger in the CB than in the LB group. No periprocedural complications occurred. During a mean follow-up of 326±142 days, 4/20 and 5/20 patients experienced an AF/AT recurrence in the CB and LB groups, respectively. No differences in clinical outcome were observed between patients with a large (≥55%) or small (<55%) ISA. Conclusions:Balloon-guided PVI is associated with antral lesion formation. CB-guided PVI is associated with the largest ISA as compared with LB procedures. ISA size did not correlate with clinical outcome after a single procedure in the present study population.

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Catheter Ablation of Long‐Standing Persistent Atrial Fibrillation: A Lesson from Circumferential Pulmonary Vein Isolation

Abstract: CPVI alone is sufficient to restore SR in 43.2% of patients with long-standing persistent AF. Multiple procedures and additional ablation strategies with a significant risk of inadvertent left atrial appendage isolation are often required to maintain stable SR.

Cited by 100 publications

References 47 publications

Left Atrial Appendage Electrical Isolation and Concomitant Device Occlusion to Treat Persistent Atrial Fibrillation

Left Atrial Appendage Electrical Isolation and Concomitant Device Occlusion to Treat Persistent Atrial Fibrillation

Pulmonary Veins to Left Atrium Cycle Length Gradient Predicts Procedural and Clinical Outcomes of Persistent Atrial Fibrillation Ablation

What Is the Acute Antral Lesion Size After Pulmonary Vein Isolation Using Different Balloon Ablation Technologies?

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