Characterization of non-pulmonary vein foci with an EnSite array in patients with paroxysmal atrial fibrillation

Yamaguchi, Takanori; Tsuchiya, Takeshi; Miyamoto, Koji; Nagamoto, Yasutsugu; Takahashi, Naohiko

doi:10.1093/europace/euq326

Cited by 47 publications

(32 citation statements)

References 29 publications

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“…24,25 We achieved success with a single PVI procedure in terms of freedom from AF and MRT for >80% of our patients, which is a high success rate among related studies to date. 20,26 Furthermore, in the groups with a large PVAI (groups III and IV), only 1 of 55 patients (1.8%) suffered from AF recurrence.…”

Section: Mechanism Of Af and Mrt Recurrences And Clinical Implicationmentioning

confidence: 58%

Quantitative Analysis of Isolation Area and Rhythm Outcome in Patients With Paroxysmal Atrial Fibrillation After Circumferential Pulmonary Vein Antrum Isolation Using the Pace-and-Ablate Technique

Kiuchi

Kircher

Watanabe

et al. 2012

Circ: Arrhythmia and Electrophysiology

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Background-We sought to determine the relationship between the size of the left atrial isolated surface area (ISA) after pulmonary vein antrum isolation for paroxysmal atrial fibrillation (AF) and rhythm outcome during a 12-month follow-up. Methods and Results-One hundred one consecutive patients with paroxysmal AF (mean age, 59±11 years; median [range] AF history, 36 months; mean left atrial size, 42±6 mm) were enrolled. The ISA was defined as the ratio of the total isolated antral surface area excluding the pulmonary veins to the sum of the total isolated antral surface area and the left atrial posterior wall surface area, while considering the individual characteristics of antral anatomy. All surface areas were assessed using the NavX system. Patients were divided into 4 groups according to ISA (group I: <50%; group II: 50 to <60%; group III: 60 to <70%; group IV: ≥70%). The average ISA for all patients was 59.2±11.6%. Subgroup analysis showed that ISA was 42.8±4.2% in group I (n=23), 54.2±3.0% in group II (n=23), 64.3±3.0% in group III (n=33), and 73.9±3.6% in group IV (n=22). After a 12-month follow-up period, 70% of patients in group I, 78% in group II, 97% in group III, and 100% in group IV were free from AF and atrial macroreentrant tachycardia. There was a significant difference between groups I and III, I and IV, II and III, and II and IV but not groups I and II and groups III and IV (logrank test P=0.024, 0.016, 0.037, 0.044, 0.584, and 0.500, respectively). Receiver operating characteristic curve analysis yielded an optimal cutoff value of 55% for ISA. Conclusions-After Methods Patient SelectionThe study was conducted on 101 consecutive patients with highly symptomatic, medically refractory paroxysmal AF, who had been treated with PVAI between January and December 2009. Paroxysmal AF was defined as a self-terminating AF of <1 week duration. Mapping and Ablation ProcedureBefore the procedure, transesophageal echocardiography was performed to exclude thrombus formation. Patients were studied under deep propofol sedation, breathing spontaneously. Standard electrode catheters were placed in the right ventricular apex and the coronary sinus, after which a single transseptal puncture was made. Unfractionated heparin was administered in bolus form immediately after the transseptal puncture to maintain an activated clotting time of >250 s. If AF occurred an external electrical cardioversion was performed to restore sinus rhythm. Mapping and ablation were performed using the NavX system (St. Jude Medical, Inc, St. Paul, MI) as a guide after integration of a 3-dimensional model of the left atrium (LA) and PV anatomy obtained from preinterventional computed tomography (CT), as described previously. 10 Before the ablation, the circular mapping catheter-reconstructed PV anatomies were aligned with the CT-PVs. Furthermore, the multipolar mapping catheter was replaced by a 4-mm M-curve irrigated tip ablation catheter (IBI Therapy Cooled Path; St Jude Medical, Inc). Fine adjustment of image integration was ach...

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Section: Mechanism Of Af and Mrt Recurrences And Clinical Implicationmentioning

confidence: 58%

Quantitative Analysis of Isolation Area and Rhythm Outcome in Patients With Paroxysmal Atrial Fibrillation After Circumferential Pulmonary Vein Antrum Isolation Using the Pace-and-Ablate Technique

Kiuchi

Kircher

Watanabe

et al. 2012

Circ: Arrhythmia and Electrophysiology

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“…Other possibilities include the presence of non-PV triggers and an ostial level of electric isolation that largely excludes areas in the antrum that may be responsible for the initiation and perpetuation of AF. 16,17 We previously have shown that the level of electric isolation with the first generation VGLA catheter is at the PV ostium. 2 The level of isolation with the current generation VGLA catheter has not been systematically evaluated.…”

Section: Efficacy Of the Vgla Cathetermentioning

confidence: 99%

Pulmonary Vein Isolation Using a Visually Guided Laser Balloon Catheter

Dukkipati

Kuck

Neužil

et al. 2013

Circ: Arrhythmia and Electrophysiology

105

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Background-Because of the technical difficulty with achieving pulmonary vein (PV) isolation in the treatment of patients with paroxysmal atrial fibrillation, novel catheter designs to facilitate the procedure are in development. A visually guided laser ablation (VGLA) catheter was designed to allow the operator to directly visualize target tissue for ablation and then deliver laser energy to perform point-to-point circumferential ablation. Single-center studies have demonstrated favorable safety and efficacy. We sought to determine the multicenter feasibility, efficacy, and safety of performing PV isolation using the VGLA catheter. Methods and Results-This study includes the first 200 paroxysmal atrial fibrillation patients treated with the VGLA catheter (33 operators, 15 centers). After transseptal puncture, the VGLA catheter was used to perform PV isolation. Electric isolation was assessed using a circular mapping catheter. Using the VGLA catheter, 98.8% (95% confidence interval, 97.8%-99.5%) of targeted PVs were isolated using a mean of 1.07 catheters per patient. Fluoroscopy and procedure times were 31±21 (mean±SD) and 200±54 minutes, respectively, and improved with operator experience. There were no instances of stroke, transient ischemic attack, atrioesophageal fistulas, or significant PV stenosis. There was a 2% incidence of cardiac tamponade and a 2.5% incidence of phrenic nerve palsy. At 12 months, the drug-free rate of freedom from atrial arrhythmias after 1 or 2 procedures was 60.2% (95% confidence interval, 52.7%-67.4%). Conclusions-In MethodsThe study consists of 200 patients (out of a consecutive series of 204 patients) enrolled in 1 US study (9 clinical sites) and 3 European studies (6 clinical sites). Of note, 4 additional patients who underwent ablation near the end of the 200-patient series were excluded as baseline demographics, and procedural data were not available at the time of data analysis; however, none of these excluded patients experienced any procedural complications. All of the studies were approved by institutional review committees at the participating institutions, and all subjects gave informed consent. The authors had full access to and take full responsibility for the integrity of the data. All authors have read and agreed with the article as written. Patient Selection and Study DesignAll 4 clinical studies were open label, nonrandomized studies of patients with symptomatic, recurrent, paroxysmal AF. There were only minimal differences in the inclusion criteria between the studies. Key inclusion criteria were age 18 to 75 years and recurrent paroxysmal AF that was refractory to ≥1 antiarrhythmic drug (Class I-IV). All patients were otherwise deemed to be candidates for catheter ablation. Key exclusion criteria included: a left ventricular ejection fraction <30%, left atrial (LA) diameter >5 cm, PV diameters >32 mm (for oval PVs, the mean values of the major and minor dimensions were used), the presence of an intracardiac thrombus, previous cardiac ablation, myocardial infarct...

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“…All 75 patients had ectopies initiating AF or AT; 48 of these patients had PV foci alone (59 foci) and 17 had non-PV foci (19 foci). 33 It was noted that 71% of the patients with non-PV foci had PV foci as well. The non-PV foci were frequently located at the LA roof and SVC, with less frequent locations in the LA, RA, CS ostium and so on.…”

Section: Atrial Fibrillation (Af)mentioning

confidence: 99%

“…30 The PVs play an important role in initiating and maintaining AF in AF patients, and PV isolation is the cornerstone of all procedures of AF ablation, 31,32 in which AF is eliminated in 80-90% of those with paroxysmal AF and in 60-70% of those with persistent AF, depending on the ongoing AF duration. 28,29 Non-PV foci are also found in 20% of AF patients, 33 which is related to recurrence after PV isolation. Episodes from non-PV foci are unpredictable and transient, and can easily change into AF.…”

Section: Atrial Fibrillation (Af)mentioning

confidence: 99%

Three-Dimensional Mapping of Cardiac Arrhythmias

Tsuchiya¹

2012

Circ J

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Characterization of non-pulmonary vein foci with an EnSite array in patients with paroxysmal atrial fibrillation

Abstract: Non-PV foci are prevalent in the LA roof and SVC sites, but can originate from other sites as well. When non-PV foci are observed, PVI may be insufficient and should be supplemented with non-PV foci ablation.

Cited by 47 publications

References 29 publications

Quantitative Analysis of Isolation Area and Rhythm Outcome in Patients With Paroxysmal Atrial Fibrillation After Circumferential Pulmonary Vein Antrum Isolation Using the Pace-and-Ablate Technique

Quantitative Analysis of Isolation Area and Rhythm Outcome in Patients With Paroxysmal Atrial Fibrillation After Circumferential Pulmonary Vein Antrum Isolation Using the Pace-and-Ablate Technique

Pulmonary Vein Isolation Using a Visually Guided Laser Balloon Catheter

Three-Dimensional Mapping of Cardiac Arrhythmias

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