Left Mitral Isthmus Ablation Associated with PV Isolation: Long‐Term Results of a Prospective Randomized Study

Fassini, Gaetano; Riva, Stefania; Chiodelli, R.; Trevisi, Nicola; Berti, Marco; Carbucicchio, Corrado; Maccabelli, Giuseppe; Giraldi, Francesco; Bella, Paolo Della

doi:10.1111/j.1540-8167.2005.50192.x

Cited by 205 publications

(228 citation statements)

References 27 publications

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“…5,8,10 Furthermore, additional linear ablation demonstrated better clinical outcomes in another 3 randomized trials. 6,7,12 Nonetheless, results of other trials did not show a clinical benefit of additional CFAE ablation, 4,9 and the recently published STAR AF II trial revealed no difference in clinical outcomes when comparing stand-alone PVI to PVI plus additional CFAE or linear ablation in a large cohort of patients with persistent AF. 13 The stepwise ablation approach was first investigated by Haïssaguerre et al 15 and consisted of the sequential combination of PVI and additional ablation of CFAEs and, in case of conversion to AT during the ablation procedure, linear ablation; in that original study, 95% of patients were in SR after 1 year and multiple ablation procedures.…”

Section: Current Ablation Strategies For Chronic Afmentioning

confidence: 90%

“…Six (5%) of the 124 patients withdrew their consent during follow-up and were excluded from the study, resulting in a total of 118 Duration of AF, mo 12 [7,24] 12 [7,24] 12 [7,24] Type of AF Persistent 69 (59) 35 (57) 34 (60) Long-standing persistent 49 (42) 26 (43) 23 (40) CAD 11 (9) 5 (8) 6 (11) Valvular disease 14 (12) 8 (13) 6 (11) Hypertension 64 (54) 35 (57) 29 (51) Diabetes mellitus 9 (8) 5 (8) 4 (7) CHADS 2 score (87) 52 (85) 51 (90) 2-3 14 (12) 8 (13) 6 (11) Values are mean±SD, median [first quartile, third quartile], or n (%). AF indicates atrial fibrillation; BMI, body mass index; CAD, coronary artery disease; CHADS 2 , stroke risk score based on congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke/transient ischemic attack/thromboembolism; CHA 2 DS 2 -VASc, stroke risk score based on congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke/ transient ischemic attack/thromboembolism, vascular disease, age 65-74 years, sex; LA, left atrium; and LVEF, left ventricular ejection fraction.…”

Section: Patientsmentioning

confidence: 99%

“…3 The optimal strategy for persistent AF is not known, and previous studies investigating more extensive ablation strategies in addition to PVI demonstrated heterogeneous results. [4][5][6][7][8][9][10][11][12] The recently published STAR AF 2 trial (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial) compared initial stand-alone PVI to PVI with additional ablation of complex fractionated atrial electrograms (CFAEs) or additional linear ablation and could not demonstrate a superior outcome for the additional ablation strategies. 13 The prospective and randomized Alster-Lost-AF © 2017 American Heart Association, Inc.…”

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confidence: 99%

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Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Fink

Schlüter

Heeger

et al. 2017

Circ: Arrhythmia and Electrophysiology

148

105

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C atheter ablation has become a routine treatment option for patients experiencing symptomatic paroxysmal atrial fibrillation (AF). Long-term clinical success rates of ≤80% after 5 years have been reported for the treatment of paroxysmal AF by initial stand-alone pulmonary vein isolation (PVI) as the accepted cornerstone of all AF ablation strategies; however, to achieve permanent PVI, multiple procedures are often required. 1,2 In contrast, the results for ablation of persistent AF are less convincing. 3 The optimal strategy for persistent AF is not known, and previous studies investigating more extensive ablation strategies in addition to PVI demonstrated heterogeneous results. [4][5][6][7][8][9][10][11][12] The recently published STAR AF 2 trial (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial) compared initial stand-alone PVI to PVI with additional ablation of complex fractionated atrial electrograms (CFAEs) or additional linear ablation and could not demonstrate a superior outcome for the additional ablation strategies. 13 The prospective and randomized Alster-Lost-AF © 2017 American Heart Association, Inc. Original ArticleBackground-Pulmonary vein isolation (PVI) for persistent atrial fibrillation is associated with limited success rates and often requires multiple procedures to maintain stable sinus rhythm. In the prospective and randomized Alster-Lost-AF trial (Ablation at St. Georg Hospital for Long-Standing Persistent Atrial Fibrillation), we sought to assess, in patients with symptomatic persistent or long-standing persistent atrial fibrillation, the outcomes of initial ablative strategies comprising either stand-alone PVI (PVI-only approach) or a stepwise approach of PVI followed by complex fractionated atrial electrogram ablation and linear ablation (Substrate-modification approach). Methods and Results-Patients were randomized 1:1 to stand-alone PVI or PVI plus substrate modification. The primary study end point was freedom from recurrence of any atrial tachyarrhythmia, outside a 90-day blanking period, at 12 months. A total of 124 patients were enrolled, with 118 patients included in the analysis (61 in the PVI-only group, 57 in the Substrate-modification group). Atrial tachyarrhythmias recurred in 28 PVI-only group patients and 24 Substratemodification group patients, for 1-year freedom from tachyarrhythmia recurrence after a single ablation procedure of 54% (95% confidence interval, 43%-68%) in the PVI-only and 57% (95% confidence interval, 46%-72%) in the Substratemodification group (P=0.86). Twenty-four patients in the PVI-only group (39%) and 18 in the Substrate-modification group (32%) were without arrhythmia recurrence and off antiarrhythmic drug therapy at the end of the 12-month follow-up. Conclusions-In

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Section: Current Ablation Strategies For Chronic Afmentioning

confidence: 90%

Section: Patientsmentioning

confidence: 99%

mentioning

confidence: 99%

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Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Fink

Schlüter

Heeger

et al. 2017

Circ: Arrhythmia and Electrophysiology

148

105

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“…However, when the same approaches are applied to persistent or long-standing persistent AF patients, the clinical success has been limited 2,3 and has led to the search for the ideal ablation strategy. The vast contrast in success suggests that the mechanisms underlying the maintenance of persistent AF are different to their paroxysmal counterparts.…”

Section: Introductionmentioning

confidence: 99%

Outcomes of long-standing persistent atrial fibrillation ablation: A systematic review

et al. 2010

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“…1,2,18) However, left mitral isthmus ablation, left atrial roof linear ablation, and linear catheter ablation to transect the anterior left atrium were shown to be necessary to maintain sinus rhythm particularly in patients with persistent AF. [19][20][21] Furthermore, in patients with persistent and permanent AF, circumferential PV ablation, combined with linear lesions in the right atrium in addition to left atrial and CS ablation, is reported to be feasible and safe, with a significantly high success rate. 22,23) However, creating transmural linear lesions with a multipolar ablation system or by the pull-back approach is difficult.…”

Section: Discussionmentioning

confidence: 99%

Temperature-Controlled Cooled-Tip Radiofrequency Linear Ablation of the Atria Guided by a Realtime Position Management System

et al. 2011

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SummaryDue to the difficulty in producing a transmural linear lesion and the possibility of complications such as thrombus formation leading to thromboembolism, the catheter-based maze procedure remains problematic.We tested, in pigs, the possibility of using a temperature-controlled cooled-tip radiofrequency (RF) ablation system together with a realtime position management (RPM) system to create a transmural linear lesion uncomplicated by thrombus formation.Nine pigs underwent insertion of two electrode catheters (each with two ultrasound electrodes), one into the coronary sinus (CS) and one into the right ventricular apex (references for ultrasound-based non-fluoroscopic three-dimensional mapping). A cooled-tip catheter (with two ultrasound electrodes) was introduced into the right atrium. Linear right atrial ablation was performed with a custom radiofrequency (RF) generator. The catheter was perfused with 0.66 mL/ second of saline. RF was delivered for 60 seconds at a target temperature of 40°C. A linear ablation line was created between the superior vena cava and inferior vena cava. Three-dimensional isochronal maps were created during CS pacing before and after ablation.In 4 of the 9 pigs, a transmural linear ablation line was confirmed by three-dimensional mapping and postmortem macroscopic examination. No endocardial thrombus formation was noted.Temperature-controlled cooled-tip RF linear ablation guided by an RPM system appears to have potential for creating linear lesions in the atria. Further studies are needed to determine whether such an ablation technique and the parameters used will facilitate successful completion of the catheter-based maze procedure. (Int Heart J 2011; 52: 50-55) Key words: Cooled-tip ablation, Atrium, Three-dimensional mapping, Linear ablation P ulmonary vein (PV) isolation is an established treatment for paroxysmal atrial fibrillation (AF), and the success rate is relatively high.1,2) However, persistent AF often requires atrial linear ablation.3,4) Irrigated-tip catheter ablation has been shown to facilitate bidirectional conduction block in the atria.5,6) However, there is greater discrepancy between measured electrode tip temperature and actual tissue temperature than with a standard ablation catheter; thus, there is greater potential for excessive but unrecognized heating within the myocardium. 7,8) This overheating results in the boiling of any water in the tissues and the creation of steam, which erupts through the tissue surface and is heard as a pop. We have shown the feasibility of temperature-controlled cooled-tip radiofrequency (RF) ablation in in vivo experiments. 9) However, precise positioning of the ablation catheter by fluoroscopy only is difficult and time consuming, resulting in long fluoroscopy times. RF catheter ablation procedures may be facilitated using additional endocardial mapping techniques; however, current available techniques are limited. Single electrode mapping or the use of multiple catheters is time consuming, and geometric reconstruction is di...

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Left Mitral Isthmus Ablation Associated with PV Isolation: Long‐Term Results of a Prospective Randomized Study

Abstract: The addition of mitral isthmus line to the PV disconnection allows a significant improvement of sinus rhythm maintenance rate, particularly in patients with persistent AF, without the risk for major complications.

Cited by 205 publications

References 27 publications

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Outcomes of long-standing persistent atrial fibrillation ablation: A systematic review

Temperature-Controlled Cooled-Tip Radiofrequency Linear Ablation of the Atria Guided by a Realtime Position Management System

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