Circumferential Pulmonary Vein Ablation With Additional Linear Ablation Results in an Increased Incidence of Left Atrial Flutter Compared With Segmental Pulmonary Vein Isolation as an Initial Approach to Ablation of Paroxysmal Atrial Fibrillation

Abstract

Background— There has been growing concern that linear ablation is associated with an increased risk of iatrogenic arrhythmias in patients undergoing ablation for atrial fibrillation (AF). Therefore, we compared circumferential pulmonary vein ablation plus left atrial linear ablation (CPVA+LALA) with segmental pulmonary vein isolation (PVI)in patients with paroxysmal AF. Methods and Results— Sixty-six consecutive patients with paroxysmal AF were prospectively randomly assigned to receive PVI versus CPVA+LALA (consisting of encircling lesions around the pulmonary veins), a roof line, and a mitral isthmus line with documentation of bidirectional mitral isthmus block. All patients were seen at 1, 3, 6, and every 12 months after ablation, with 14-day continuous ECG monitoring every 6 months. At 16.4±6.3 months after 1 ablation procedure, 19 patients (58%) remained free of atrial arrhythmias after PVI versus 17 patients (51%) after CPVA+LALA ( P =0.62). After PVI, 14 patients had recurrent paroxysmal AF, whereas after CPVA+LALA, 8 patients had recurrent AF, 6 had atypical left atrial flutter (LAFL), and 2 had both AF and LAFL ( P =0.32 between PVI versus CPVA+LALA for AF but P =0.002 for LAFL). Twenty-eight patients (85%) remained arrhythmia-free after 1.3±0.5 PVI procedures versus 28 patients (85%) after 1.4±0.6 CPVA+LALA procedures ( P =NS). Fluoroscopy time was longer after CPVA+LALA versus PVI (91 versus 73 minutes, P =0.04). Conclusions— As an initial ablation approach in patients with paroxysmal AF, more LAFL occurred after CPVA+LALA and fluoroscopy times were longer compared with segmental PVI.

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…253,436,507,508,622,623, 624,625,630,870,871,995,996,997,998,999,1000,1001,1002 Most of these tachycardias originate in the LA, although RA cavotricuspid isthmus (CTI)-dependent flutters might also occur. Patients with a regular AT of new onset might complain of worsening symptoms due to a faster mean ventricular rate (frequently 2:1 ventricular response) than that during AF preablation.…”

Predictors of early and late left atrial tachycardia and left atrial flutter after catheter ablation of atrial fibrillation: Long-term follow-up

“…Nevertheless, performing linear lesions in dilated LA can be challenging due to the fact thatthey have to be longer than in not-dilated LA. The vast majority of arrhythmias that occur after CAAF are re-entrant (83%) [1][2][3][4][5][6][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] and use gaps in prior ablation lines. Elimination of the dominant arrhythmia may uncover, suppressed so far, ectopic foci.…”

Pearls and Pitfalls in Catheter Ablation of Persistent Atrial Fibrillation

“…26 In the study by Sawhney et al, more patients developed LA flutter after PV isolation plus linear ablations, compared with segmental PV isolation alone. 27 In our recent study of patients who received multiple AF ablation procedures, the incidence of atypical flutter or atrial tachycardia was approximately 30% after a second procedure. 28 It is possible that linear ablation used in a stepwise ablation strategy in the index procedure is proarrhythmic during long-term follow-up.…”