How to perform posterior wall isolation in catheter ablation for atrial fibrillation

Abstract

Catheter ablation has become standard of care in patients with symptomatic atrial fibrillation (AF). Although there have been significant advances in our understanding and technology, a substantial proportion of patients have ongoing AF requiring repeat procedures. Pulmonary vein isolation (PVI) is the cornerstone of AF ablation; however, it is less effective in patients with persistent as opposed to paroxysmal atrial fibrillation. Left atrial posterior wall isolation (PWI) is commonly performed as an adjunct to PVI in patients with persistent AF with nonrandomized studies showing improved outcomes. Anatomical considerations and detailed outline of the various approaches and techniques to performing PWI are detailed, and advantages and pitfalls to assist the clinical electrophysiologist successfully and safely complete PWI are described.

Comparison of treatment outcomes between convergent procedure and catheter ablation for paroxysmal atrial fibrillation evaluated with implantable loop recorder monitoring

“…Long‐term AF burden discrepancy implies that in patients with paroxysmal AF, additional extensive ablation of the LA posterior wall in CVP, in contrast to CA, could play a role on the long‐term sinus rhythm maintenance. Some data exist supporting ablation of the embryologically similar PV antra and LA posterior wall as a continuity in the treatment of AF . Moreover, the epicardial lesion pattern utilized in this study has also shown good long‐term outcomes in a mostly persistent AF patient population with 31% and 36% recurrence rates (cutoff of 1% AF burden) after 1 and 4 years of ILR monitoring …”

“…16,17 Outcomes, even for paroxysmal AF patients who maintained sinus rhythm off AADs at 1 year, have been shown to decline throughout long-term follow-up. 18,19 [20][21][22] Moreover, the epicardial lesion pattern utilized in this study has also shown good long-term outcomes in a mostly persistent AF patient population with 31% and 36% recurrence rates (cutoff of 1% AF burden) after 1 and 4 years of ILR monitoring. 23 Procedural duration did not differ significantly between both groups, which can be attributed to much shorter duration of the endocardial part of the procedure in the CVP group.…”

Differences in the electrophysiological findings of repeat ablation between patients who first underwent cryoballoon ablation and radiofrequency catheter ablation for paroxysmal atrial fibrillation

“…PV isolation was extensively performed in all cases, and 70.4% of RF cases underwent creation of the right posterior wall line adjacent to the left posterior wall line. This method, which is called the touching rings method, can be used to isolate the PV antrum and part of the LA posterior wall (Figure ). After PV isolation, isoproterenol (5‐20 µg/min) was intravenously injected, and atrial burst pacing (140‐240 ms) was performed to induce non‐PV AF foci .…”

The pulmonary vein meets the left atrium: The where and why of pulmonary vein isolation

“…It is those cylinder‐like “veins” that drain into the left atrium. As noted by the authors, embryologically, the pulmonary veins unite to a common antrum that then is resorbed as it meets the primordial left atrium such that the posterior wall is the pulmonary vein along with the cylindrical components draining oxygenated blood from the lungs. Specifically, histologically as well as developmentally, the posterior wall and the vein‐like structures draining are indistinguishable with both components having varying amounts of atrial myocardium wrapping around the primary venous components…”

“…The purpose of the “Techniques, Technology, and Innovation” section in the Journal of Cardiac Electrophysiology is primarily to highlight the methodological details of executing proven effective electrophysiology procedures. A prime example in the present issue is by Sugumar et al . on how to conduct one of the most challenging isolation procedures in our field.…”