Clinical impact of eliminating nonpulmonary vein triggers of atrial fibrillation and nonpulmonary vein premature atrial contractions at initial ablation for persistent atrial fibrillation

Fukunaga, Masato; Nagashima, Michio; Korai, Kengo; Hirokami, Jun; Yamamoto, Kei; Takeo, Ayaka; Niu, Harushi; Ando, Kenji; Hiroshima, Kenzo

doi:10.1111/jce.14830

Cited by 26 publications

(30 citation statements)

References 31 publications

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“…The prevalence of non-PV trigger in AF ablation has been reported from 5% to 30%, however, non-PV trigger was detected in 35 among 751 sessions (4.7%) in this study and its rate was lower than the previous studies [ 12 , 23 , 24 ]. This may be related to the different induction manners such as the dose of drugs and the conditions of the patients [ 25 – 27 ].…”

Section: Discussioncontrasting

confidence: 87%

“…The efficacy of linear-based ablation has been inconsistent among studies, which may be due to the different degree of atrial degeneration and the various mechanisms of AF in every patient [ 4 , 20 ]. In contrast, non-PV trigger ablation is a unique approach for each patient and could theoretically target every AF initiation [ 12 , 21 ]. We previously reported that ablation outcome in AF patients with non-PV triggers could be improved to the level of those without non-PV triggers, by selective mapping and ablation of non-PV triggers [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

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Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation

et al. 2022

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Background Pulmonary vein isolation (PVI) is an established ablation procedure for atrial fibrillation (AF), however, PVI alone is insufficient to suppress AF recurrence. Non-pulmonary vein (non-PV) trigger ablation is one of the promising strategies beyond PVI and has been shown to be effective in refractory/persistent AF cases. To make non-PV trigger ablation more standardized, it is essential to develop a simple method to localize the origin of non-PV triggers. Methods We retrospectively analyzed 37 non-PV triggers in 751 ablation sessions for symptomatic AF from January 2017 to December 2020. Regarding non-PV triggers, intra-atrial activation interval from the earliest in right atrium (RA) to proximal coronary sinus (CS) (RA-CSp) and that from the earliest in RA to distal CS (RA-CSd) obtained by a basically-positioned duodecapolar RA-CS catheter were compared among 3 originating non-PV areas [RA, atrial septum (SEP) and left atrium (LA)]. Results RA-CSp of RA non-PV trigger (56.4 ± 23.4 ms) was significantly longer than that of SEP non-PV (14.8 ± 25.6 ms, p = 0.019) and LA non-PV (-24.9 ± 27.9 ms, p = 0.0004). RA-CSd of RA non-PV (75.9 ± 32.1 ms) was significantly longer than that of SEP non-PV (34.2 ± 32.6 ms, p = 0.040) and LA non-PV (-13.3 ± 41.2 ms, p = 0.0008). RA-CSp and RA-CSd of SEP non-PV were significantly longer than those of LA non-PV (p = 0.022 and p = 0.016, respectively). Sensitivity and specificity of an algorithm to differentiate the area of non-PV trigger using RA-CSp (cut-off value: 50 ms) and RA-CSd (cut-off value: 0 ms) were 88% and 97% for RA non-PV, 81% and 73% for SEP non-PV, 65% and 95% for LA non-PV, respectively. Conclusions The analysis of intra-atrial activation sequences was useful to differentiate non-PV trigger areas. A simple algorithm to localize the area of non-PV trigger would be helpful to identify non-PV trigger sites in AF ablation.

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Section: Discussioncontrasting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation

et al. 2022

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“… 1 , 3 The complete elimination of the non-PV foci results in a significant improvement in terms of AF recurrence rates compared to those in patients in whom non-PV triggers were not completely eliminated. 4 , 5 This report shows that FAAM ablation was effective in eliminating the non-PV foci in patients with refractory AF. Therefore, AF recurrence was potentially improved.…”

Section: Discussionmentioning

confidence: 79%

“… 1 , 2 , 3 Non–pulmonary vein (PV) trigger elimination can improve the recurrence rate after paroxysmal and persistent AF ablation. 4 , 5 However, complete non-PV trigger elimination is challenging owing to difficulty in detecting the non-PV foci. We developed a novel visualization tool of the fractionated signal area in the atrial muscle (FAAM) map, which highlights the fractionated signal area using Lumipoint software in the ultra-high-density Rhythmia (Boston Scientific, Marlborough, MA) system and successfully identifies the non-PV foci.…”

Section: Introductionmentioning

confidence: 99%

A novel ablation strategy for refractory atrial fibrillation based on the fractionated signal area in the atrial muscle

Hirokami

Hiroshima

Nagashima

et al. 2021

HeartRhythm Case Reports

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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“…Specifically, in the LVA approach group, the recurrence rate tended to be higher in patients without LVA (PVI alone) than in those with LVA (PVI plus LVA ablation). Although we acknowledge the limitation of our small sample size, an alternative ablation approach (e.g., non-PV trigger ablation) may be required to improve the outcome in PeAF patients without LVA [ 36 – 38 ]; at the very least, additional linear ablation or PVI alone according to the assessment of the LA voltage map might not be sufficient for PeAF patients without evidence of LVA or documented AFL.…”

Section: Discussionmentioning

confidence: 99%

Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis

Suzuki

Kaneko

Fujita

et al. 2022

BMC Cardiovasc Disord

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Background The efficacy of pulmonary vein isolation (PVI) alone is not guaranteed for persistent atrial fibrillation (PeAF), and it is unclear which type of ablation approach should be applied in addition to PVI. This study aimed to compare outcomes and prognosis between empirical linear ablation and low-voltage area (LVA) ablation after PVI for PeAF. Methods We enrolled 128 patients with PeAF who were assigned to the linear ablation group (n = 64) and the LVA ablation group (n = 64) using a propensity score-matched model. After PVI and cardioversion, the patients underwent either empirical linear ablation or LVA ablation during sinus rhythm. All patients in the linear ablation group underwent both roof line and mitral valve isthmus (MVI) ablations. An electrical-guided ablation targeting LVA (< 0.5 mV) was performed in the LVA group. When there was no LVA in the LVA group, only PVI was applied. We compared the procedural outcomes and recurrence after ablation between the two groups. Results The baseline characteristics were well-balanced between the two groups. Fifty patients had LVA (22 and 28 patients in the linear and LVA groups). The roof and MVI lines were completed in 100% and 96.9% of the patients. During the mean follow-up of 279.5 ± 161.3 days, the LVA group had significantly lower recurrence than the linear group (15 patients [23%] vs. 29 patients [45%], p = 0.014). Thirty-five patients were prescribed antiarrhythmic drugs during the follow-up period (linear group, n = 17; LVA group, n = 18); amiodarone and bepridil were administered to most of the patients (15 and 17 patients, respectively). The difference in the prognosis was relevant among the patients with LVA, while this trend was not observed in those without LVA. The LVA ablation group demonstrated significantly lower radiofrequency energy and shorter procedural time compared to the linear ablation group. The recurrence of atrial flutter was more likely to occur in the linear group than in the LVA group (14 [22%] vs. 6 [9.4%], p = 0.052). Conclusion The electrophysiological-guided LVA ablation is more effective than empirical linear ablation in PeAF patients with LVA. Unnecessary empirical linear ablation might have a risk of iatrogenic gap and atrial flutter recurrence.

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Clinical impact of eliminating nonpulmonary vein triggers of atrial fibrillation and nonpulmonary vein premature atrial contractions at initial ablation for persistent atrial fibrillation

Cited by 26 publications

References 31 publications

Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation

Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation

A novel ablation strategy for refractory atrial fibrillation based on the fractionated signal area in the atrial muscle

Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis

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