Frequency Gradient Within Coronary Sinus Predicts the Long‐Term Outcome of Persistent Atrial Fibrillation Catheter Ablation

Abstract

BackgroundThe coronary sinus (CS), as a junction of the atria, contributes to atrial fibrillation (AF) by developing unstable reentry, and isolating the atria by ablation at the CS could terminate AF. The present study evaluated whether AF activities at the CS in a subset of patients contributed to AF maintenance and predicted clinical outcome of ablation.Methods and ResultsWe studied 122 consecutive patients who had a first‐time radiofrequency ablation for persistent AF. Bipolar electrograms were obtained from multiple regions of the left atrium by a Lasso mapping catheter before ablation. Pulmonary vein isolation terminated AF in 12 patients (9.8%). Sequential stepwise ablation was conducted in pulmonary vein isolation nontermination patients and succeeded in 22 patients (18%). In the stepwise termination group, AF frequency in the proximal CS (CSp) was significantly higher (10.2±2.1 Hz versus 8.3±1.8 Hz, P<0.001), and the ratio of distal CS (CSd) to proximal CS (CSd/CSp ratio, 56.6%±10.11% versus 70.7%±9.8%, P<0.001) was significantly lower than that in the nontermination group. The stepwise logistic regression analysis indicated that the CSd/CSp ratio was an independent predictor with an odds ratio of 1.131 (95%CI 1.053‐1.214; P=0.001). With a cutoff of 67%, the patients with lower CSd/CSp ratios had significantly better index and long‐term outcomes than those with higher ratios during a follow‐up of 46±18 months.ConclusionsRapid repetitive activities in the musculature of the proximal CS may contribute to maintenance of AF after pulmonary vein isolation alone in persistent AF. A cutoff at 67%, of the CSd/CSp frequency ratio might be an indicator to stratify the subset of patients who might benefit from CS ablation.

Focal impulse and rotor modulation of atrial rotors during atrial fibrillation leads to organization of left atrial activation as reflected by waveform morphology recurrence quantification analysis and organizational index

“…While there have been several applications of frequency domain analysis and morphology RQA techniques in the setting of catheter ablation of AF, to the best of our knowledge, there has been no study to date that has shown changes in EGMs as a result of directed rotor ablation (outside of conventional pulmonary vein isolation). Previous studies have suggested the role of DF, OI, and RQA in the prediction of short‐ and long‐term outcomes in AF ablation. Several other studies have also suggested that both OI and morphology RQA may describe foci of atrial organization critical to the maintenance of AF.…”

Impact of baseline impedance of pulmonary vein antrum on success of catheter ablation for paroxysmal atrial fibrillation guided by ablation index

“…Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF) [ 1 , 2 ]. Avoiding gaps of the PVI circle is of great importance for effect of ablation.…”

Provocation and ablation of non–pulmonary vein triggers in nonparoxysmal atrial fibrillation: Role of the coronary sinus

“…On one side, ablation of the CS muscular sleeves with abolition of all electrical potentials eliminates an important source of rapid repetitive electrical activity that may be involved in AF initiation. 12,13 On the other side, CS isolation may interrupt an important electrical connection between the atria and avoid the development of unstable re-entry, thereby preventing AF perpetuation. 14,15 In a series of 45 paroxysmal and persistent AF patients, 14 RFCA targeting the CS led to significant prolongation of the fibrillatory cycle length and terminated AF in approximately 35%.…”