Efficacy of Adjuvant Anterior Left Atrial Ablation During Intracardiac Echocardiography‐Guided Pulmonary Vein Antrum Isolation for Atrial Fibrillation

Verma, Atul; Patel, Dimpi; Famy, Tamer; Martin, Maureen P.; Burkhardt, J. David; Elayi, Samy Claude; Lakkireddy, Dhanumjaya; Wazni, Oussama; Cummings, Jennifer E.; Schweikert, Robert A.; Saliba, Walid; Tchou, Patrick; Natale, Andrea

doi:10.1111/j.1540-8167.2006.00673.x

Cited by 138 publications

(75 citation statements)

References 21 publications

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“…The importance of these sites, as substrates for atrial fibrillation, has been previously demonstrated [18]. As observed in the results of this study the CFE mean map algorithm correlated very well with the human manual operator manual tagging fractionated signal corresponding to PV potentials which was used as the Gold Standard (Table 2).…”

Section: Discussionsupporting

confidence: 67%

A Feasibility Pilot Study to Assess the Efficacy of NavX Guided Detection of Pulmonary Vein Electrograms during Atrial Fibrillation Ablation [NavX Guided Detection of Pulmonary Vein Electrograms]

Khaykin¹,

Alipour²,

Pirbaglou³

et al. 2017

Int J Clin Cardiol

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Section: Discussionsupporting

confidence: 67%

A Feasibility Pilot Study to Assess the Efficacy of NavX Guided Detection of Pulmonary Vein Electrograms during Atrial Fibrillation Ablation [NavX Guided Detection of Pulmonary Vein Electrograms]

Khaykin¹,

Alipour²,

Pirbaglou³

et al. 2017

Int J Clin Cardiol

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“…We believe that due to the proximity of Bachmann bundle to the antral region of the RSPV [11] in some cases the conduction over this structure is delayed as a result of the ablation, also confirming the ablation of left atrial muscle tissue in the septal region. This has been proven to improve outcome with radiofrequency ablation [12] but for cryothermal ablation the clinical impact of this remains to be determined.…”

Section: Discussionmentioning

confidence: 99%

Electro-anatomical mapping of the left atrium before and after cryothermal balloon isolation of the pulmonary veins

Belle

Knops

Janse

et al. 2009

J Interv Card Electrophysiol

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Introduction The 28 mm cryoballoon catheter is a device used for pulmonary vein isolation (PVI). The aim of this study was to evaluate the extent of the ablation in the antral regions of the left atrium. Methods and Results Eighteen patients with drug refractory, symptomatic, paroxysmal AF were enrolled. A 3D electroanatomic reconstruction of the left atrium was made before and after successful PVI with the 28 mm cryoballoon. Markers were placed at the ostium. Sixteen patients were mapped. Fourteen patients had 4 veins each, and 2 patients had a common ostium of the left sided veins. All separate ostia were isolated in the antral region. The two common ostia showed ostial isolation. There was a significant difference in vein size between the common (29 and 31 mm) and the separate ostia (19±4 mm) (p<0.01). The performance of an additional segmental ablation if balloon PVI did not eliminate all electrical activity, did not influence the extent of the ablation. The earliest left atrial activation during sinus rhythm was located in the superior septal region before ablation in all patients. After ablation, two patients showed a substantial downward shift towards the middle and inferior septal region respectively (NS). Four patients demonstrated a slight downward shift of the first activation.Conclusions In cryoballoon PVI, the majority of the veins undergo antral isolation. Veins with a diameter larger than the balloon, are isolated ostially. In individual cases, the left atrial activation sequence appears to be altered after ablation.Keywords Ablation . Arrhythmia . Cryoballoon . Cryoablation . Catheter ablation . Tachyarrhythmias . Atrial fibrillation . Pulmonary veins IntroductionThe cryothermal balloon, or cryoballoon, is a novel technology, developed for pulmonary vein (PV) isolation. It is a catheter based device with the potential of performing a circumferential ablation, thus isolating the PV muscular sleeves in a limited number of applications. Since cryothermia causes no PV stenosis [1][2][3] the ablation can safely be performed at the ostial level of the pulmonary vein, but the question remains to what extent cryoballoon ablation modifies the left atrial substrate. After a large experience in animal testing was achieved by several authors [4][5][6][7] the first human results are promising as a treatment for paroxysmal atrial fibrillation (AF) [8]. The aim of this study was to evaluate the effect of the cryothermal balloon on the antral regions of the left atrium. Methods InclusionPatients with documented symptomatic paroxysmal AF despite antiarrhythmic drugs, at two or more occasions,

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“…54 A 200-patient case-control study demonstrated that targeting CFAEs in addition to PVI had no effect on freedom from AF in patients with paroxysmal AF and only marginally improved the success rate of PVI in the subset of patients with persistent or permanent AF (success rate 82 % for PVI and CFAE ablation vs. 72 % for PVI alone, p=0.047). 65 Multiple other studies, however, have found that targeting CFAEs provided no additional freedom from AF over PVI alone even among patients with permanent AF. 57,59,60,63 A recent meta-analysis evaluated the outcomes in 622 patients across seven trials that compared PVI with PVI plus adjunctive CFAE ablation.…”

Section: Limitations Of Targeting Rotors With Ablation For the Treatmmentioning

confidence: 99%

“…Observations that CFAE ablation without PVI results in very high rates of AF recurrence 54,[61][62][63]65 suggest that CFAEs are not drivers of AF. In fact, the vast majority of areas of observed fractionation are actually functional and passive electrophysiological manifestations.…”

Section: Complex Fractionated Electrograms Are Passive Bystanders In Afmentioning

confidence: 99%

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

Waks

Josephson²

2014

Arrhythmia &Amp; Electrophysiology Review

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Atrial fibrillation (AF), the most common sustained arrhythmia, is a leading cause of stroke, and is associated with significant morbidity and mortality worldwide. Despite its frequency, clinical importance, and advances in technology and our knowledge of the molecular, ionic and physiological fundamentals of cardiac electrophysiology, our limited understanding of the mechanisms that initiate and sustain AF has prevented us from being able to truly cure this arrhythmia with antiarrhythmic drugs and/or ablation. This contrasts with other arrhythmias, such as AV nodal tachycardia or circus movement tachycardia using an accessory pathway, which have well-defined mechanisms and circuits that can be safely targeted with high rates of cure. The observations that AF may have different mechanisms in different patients, and that paroxysmal, persistent and permanent forms of AF may differ in how they are initiated and sustained, only serves to reinforce our lack of understanding of this ubiquitous arrhythmia. Historical Mechanisms of Atrial Fibrillation and the Multiple Wavelet HypothesisInterest and understanding of the mechanism of AF began to take form in the early 1900s. Given the chaotic and irregular nature of AF on the surface electrocardiogram, rapid firing of automatic atrial foci was considered a potential mechanism. However, after the seminal work of Mayer 1 , Mines 2 and Garrey 3 in laying the foundation for describing and understanding reentrant arrhythmias, atrial reentrant circuits emerged as the likely drivers of AF.4-7 Although these theories were conceptually sound, it was impossible to prove a specific mechanism with the technology of the time. Moe et al. demonstrated that it was probabilistically unlikely that a large number of simultaneous wavefronts would all die out simultaneously, and AF would therefore perpetuate. However, if the number of simultaneous wavelets were small and/or below a critical value (between 15 and 30 in Moe's computer model), 9 at some point all reentrant wavefronts would be simultaneously extinguished, and AF would therefore terminate. 8,9 Allessie et al. provided experimental evidence supporting this mechanism in a canine heart model of AF where four to six simultaneous reentrant wavelets were needed to sustain arrhythmia. 10 Further evidence supporting multiple wavelets in AF was demonstrated in a separate model, which evaluated the effect of various antiarrhythmic drugs on canine myocardium. This model demonstrated that termination of AF was associated with a reduction AbstractAtrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, yet our understanding of the mechanisms that initiate and sustain this arrhythmia remains quite poor. Over the last 50 years, various mechanisms of AF have been proposed, yet none has been consistently observed in both experimental studies and in humans. Recently, there has been increasing interest in understanding how spiral waves or rotors -which are specific, organised forms of functional reentry -su...

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Efficacy of Adjuvant Anterior Left Atrial Ablation During Intracardiac Echocardiography‐Guided Pulmonary Vein Antrum Isolation for Atrial Fibrillation

Abstract: Adjuvant anterior LA ablation does not appear to impact procedural outcome in patients with paroxysmal AF but may offer benefit to patients with persistent/permanent AF.

Cited by 138 publications

References 21 publications

A Feasibility Pilot Study to Assess the Efficacy of NavX Guided Detection of Pulmonary Vein Electrograms during Atrial Fibrillation Ablation [NavX Guided Detection of Pulmonary Vein Electrograms]

A Feasibility Pilot Study to Assess the Efficacy of NavX Guided Detection of Pulmonary Vein Electrograms during Atrial Fibrillation Ablation [NavX Guided Detection of Pulmonary Vein Electrograms]

Electro-anatomical mapping of the left atrium before and after cryothermal balloon isolation of the pulmonary veins

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

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