Hybrid Therapy With Pilsicainide and Pulmonary Vein Isolation for Atrial Fibrillation

Abstract

, are widely used for pharmacologic cardioversion and prevention of atrial fibrillation (AF); 1,2 however, if they are ineffective, radiofrequency catheter ablation targeting the pulmonary veins (PV) can be used to cure AF. [3][4][5] It has been reported that PV isolation can result in a significant reduction in the severity of symptoms and can improve the QOL of patients with drug-refractory paroxysmal AF (PAF); 6 however, in prior studies of PV isolation, the recurrence rate has been relatively high and a repeat ablation procedure is sometimes required. [3][4][5]7 In some cases of unsuccessful ablation, antiarrhythmic agents that were ineffective before the ablation may become effective, but the mechanisms of hybrid therapy with antiarrhythmic agents and PV isolation are unclear. Therefore, we assessed the efficacy of hybrid therapy with a pure Na + channel blocker, pilsicainide, and PV isolation for PAF. Methods PatientsThe study population consisted of 74 patients (54 men, 20 women; mean age, 56±6 years) with symptomatic drugrefractory PAF who were referred for an electrophysiological study and catheter ablation. A mean of 3.0±1.0 antiarrhythmic drugs, including pilsicainide, had been Circulation Journal Vol.69, December 2005 administered unsuccessfully. None had been treated with amiodarone during the preceding 6 months. The patients had frequent episodes of PAF, frequent atrial premature beats documented by 24-h Holter monitoring, or spontaneous re-initiation of AF after defibrillation. Fifteen patients had additional cardiovascular diagnoses, including systemic hypertension in 13 and ischemic heart disease in 2. Electrophysiological StudyWritten informed consent was given by all patients. Antiarrhythmic drugs were discontinued 5 half-lives before ablation. Treatment with anticoagulants, which were taken by all of the patients, was stopped on admission. Three 6-French quadripolar electrode catheters (Daig) were placed in the right atrial appendage, His bundle area and coronary sinus. A transseptal approach was performed with an 8.5rF long sheath, both for the puncture and to introduce a 31 mm, 64-pole basket catheter (EP Technologies) dedicated to PV mapping. A 4-mm-tip conventional ablation catheter (EP Technologies) was also introduced into the left atrial (LA) for ablation. PV angiography was performed with an angiocatheter (6-Fr, Baxter) to determine the position of the basket catheter relative to the ostium of the PV. The proximal electrode (bipoles 7-8) of the basket catheter was located at the PV-LA junction. The proximal part of the PV was defined as the ostial side of the veins, and the distal was referred to as the lung side.In patients with recurrence of AF, a second session was performed. The electrophysiological study was performed to assess the effect of pilsicainide on the electrophysiological properties of PV before ablation. PV pacing was performed from the distal (bipoles 1-2) electrode pair of all splines of the basket catheter. A programmed stimulator Background Pulmonary vein (PV) isol...

Plasma Brain Natriuretic Peptide Level After Hybrid Therapy With Pulmonary Vein Isolation and Antiarrhythmic Drugs for Atrial Fibrillation

“…5,6,9,10) This study demonstrated that elevated BNP levels normalized in the patients with AF which was refractory to antiarrhythmic drugs and PVI when the AF was eliminated by the hybrid therapy with PVI followed by the administration of one antiarrhythmic drug. These findings suggest that in consideration of the neurohormonal system, hybrid therapy may be an effective therapeutic approach with which to cure recurrent AF after PVI.…”

“…9) First, the creation of pharmacologic block in partially isolated PVs may contribute to the hybrid effect. Second, antiarrhythmic drugs may not be able to suppress focal discharges from PVs, but may be able to suppress those in atrial tissue (non-PV foci).…”

“…[5][6][7][8] It has been reported that in some cases of unsuccessful ablation, antiarrhythmic drugs that were ineffective before the PVI may become effective (hybrid therapy) after. 5,9,10) However, the relationship between the BNP level and the effect of the hybrid therapy remains unknown. The purpose of this study was to investigate the relationship.…”

A Sodium Channel Blocker, Pilsicainide, Produces Atrial Post-Repolarization Refractoriness through the Reduction of Sodium Channel Availability

“…Recently, catheter ablation has prevailed as rhythm control therapy for paroxysmal AF (Wilber et al 2010), and sodium channel blockers have been re-evaluated as the combination therapy with catheter ablation (Tojo et al 2005;Kumagai et al 2006). Class I sodium channel blockers increase ERP without affecting APD, or so-called PRR.…”

Mechanisms of the Preventive Effect of Pilsicainide on Atrial Fibrillation Originating From the Pulmonary Vein

“…Moreover, a clinical study has indicated that in the case of unsuccessful PV isolation by catheter ablation, pilsicainide may prevent AF by modifying the PV-LA conduction properties. 34 Therefore, pilsicainide may be a good drug for preventing the recurrence of AF originating from the PVs after catheter ablation.…”