Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation

Bai, Rong; Biase, Luigi Di; Mohanty, Prasant; Trivedi, Chintan; Russo, Antonio Dello; Themistoclakis, Sakis; Casella, Michela; Santarelli, P; Fassini, Gaetano; Santangeli, Pasquale; Mohanty, Sanghamitra; Rossillo, Antonio; Pelargonio, Gemma; Horton, Rodney; Sánchez, Javier; Gallinghouse, Joseph G.; Burkhardt, J. David; Sheng, Chang; Tondo, Claudio; Natale, Andrea

doi:10.1016/j.hrthm.2015.08.019

Cited by 156 publications

(107 citation statements)

References 28 publications

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“…It can be argued that more extensive ablation approaches may be required to achieve better outcomes for these patients as has been shown in some nonrandomized studies that report higher rates of long-term ablation success using more extensive ablation strategies. [15][16][17] However, in all of these studies, >1 ablation attempt was required to achieve better outcomes. Furthermore, the positive results of these nonrandomized studies have never been reproduced by prospective randomized controlled trials that have consistently failed to demonstrate the benefit of more extensive ablation strategies over PVI in this patient population.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Liang¹,

Elafros²,

Muser³

et al. 2016

Circ: Arrhythmia and Electrophysiology

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A lthough pulmonary vein isolation (PVI) is well accepted to be the cornerstone of ablation for paroxysmal atrial fibrillation (AF), there remains lack of consensus on the optimal ablation strategy in patients with persistent and longstanding persistent AF. [1][2][3] Although an ablation strategy limited primarily to PVI, with or without targeting of documented nonpulmonary vein (PV) triggers, results in lower long-term AF-free survival rates in patients with persistent and longstanding persistent AF than paroxysmal AF, outcomes are not improved with more extensive substrate modification strategies.2,3 It has been shown that ≈50% of patients with persistent and long-standing persistent AF who undergo extensive substrate modification experience persistent organized atrial tachyarrhythmias (OAT) after ablation. 4,5 In contrast, patients with persistent and long-standing persistent AF treated with a more targeted ablation strategy (PVI with or without documented non-PV trigger ablation) are more likely to experience arrhythmia recurrences in the form of AF instead of OATs. However, when the arrhythmia recurrence in these patients is paroxysmal in nature, this likely suggests a favorable modification of the underlying AF substrate, which becomes less capable of sustaining AF.The objective of this study, therefore, was to determine the nature of initial arrhythmia recurrence in patients with © 2016 American Heart Association, Inc. Original ArticleBackground-Transformation from persistent to paroxysmal atrial fibrillation (AF) after ablation suggests modification of the underlying substrate. We examined the nature of initial arrhythmia recurrence in patients with nonparoxysmal AF undergoing antral pulmonary vein isolation and nonpulmonary vein trigger ablation and correlated recurrence type with long-term ablation efficacy after the last procedure. Methods and Results-Three hundred and seventeen consecutive patients with persistent (n=200) and long-standing persistent (n=117) AF undergoing first ablation were included. AF recurrence was defined as early (≤6 weeks) or late (>6 weeks after ablation) and paroxysmal (either spontaneous conversion or treated with cardioversion ≤7 days) or persistent (lasting >7 days). During median follow-up of 29.8 (interquartile range: 14.8-49.9) months, 221 patients had ≥1 recurrence. Initial recurrence was paroxysmal in 169 patients (76%) and persistent in 52 patients (24%). Patients experiencing paroxysmal (versus persistent) initial recurrence were more likely to achieve long-term freedom off antiarrhythmic drugs (hazard ratio, 2.2; 95% confidence interval, 1.5-3.2; P<0.0001), freedom on/off antiarrhythmic drugs (hazard ratio, 2.5; 95% confidence interval, 1.6-3.8; P<0.0001), and arrhythmia control (hazard ratio, 5.2; 95% confidence interval, 2.9-9.2; P<0.0001) after last ablation. Conclusions-In patients with persistent and long-standing persistent AF, limited ablation targeting pulmonary veins and documented nonpulmonary vein triggers improves the maintenance of sinus rhythm and re...

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Section: Discussionmentioning

confidence: 99%

Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Liang¹,

Elafros²,

Muser³

et al. 2016

Circ: Arrhythmia and Electrophysiology

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“…In such cases, several authors have identified additional targets for ablation outside the pulmonary veins, the so called non-PV triggers. [10][11][12] The most common non-PV trigger sites are the superior vena cava, the coronary sinus, the atrial septum, the posterior wall, the ligament of Marshall, and, more recently emphasized, the LAA. [12][13][14][15][16][17][18][19] It is important to consider that the Cox-Maze III surgery data have demonstrated a 90% success rate at maintaining sinus rhythm and a low incidence of thromboembolic events, and this procedure excludes or excises the LAA.…”

Section: See Article By Panikker Et Almentioning

confidence: 99%

Left Atrial Appendage After Electrical Isolation

Biase

2016

Circ: Arrhythmia and Electrophysiology

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T he left atrial appendage (LAA) has been considered for years as a less relevant part of the left atrium. During the years, its function and role have been extensively studied.The LAA is recognized as the major source (95%) of cardiac emboli in patients with nonvalvular atrial fibrillation (AF). In addition, the LAA has been shown to have important roles in atrial natriuretic peptide secretion and as an underreported trigger site of AF. [1][2][3][4][5][6][7] From an anatomic point of view, the LAA has a trabecular tubular shape with variable morphologies and derives from the embryonic left atrium as an outgrowth of the pulmonary veins. 6,7 See Article by Panikker et alCatheter ablation of AF is a valid therapeutic option for the treatment of AF and has been shown to be superior to antiarrhythmic drugs for maintaining sinus rhythm. 8,9 Pulmonary vein (PV) isolation is the primary target for ablation. 9 Procedural success rates vary depending on the experience of the operator and on the subtype of atrial fibrillation: higher in paroxysmal and lower in persistent and longstanding, persistent AF. Many patients continue to experience AF recurrences, despite permanent PV isolation. In such cases, several authors have identified additional targets for ablation outside the pulmonary veins, the so called non-PV triggers. 10-12The most common non-PV trigger sites are the superior vena cava, the coronary sinus, the atrial septum, the posterior wall, the ligament of Marshall, and, more recently emphasized, the LAA. [12][13][14][15][16][17][18][19] It is important to consider that the Cox-Maze III surgery data have demonstrated a 90% success rate at maintaining sinus rhythm and a low incidence of thromboembolic events, and this procedure excludes or excises the LAA. 20 The surgical data and the experience and lessons learned by burning guided our group to consider the LAA as a target for ablation.In our first series in 2010, we showed that LAA electric isolation rather than focal LAA ablation was the best strategy to maintain sinus rhythm at follow-up in a series of patients that failed previous procedures and showed sustained LAA firing. 12 We also showed that after electric isolation of the LAA, in ≈50% of cases, lifelong anticoagulation is recommended to reduce the risk of thromboembolic complications.12 To eliminate the need for lifelong anticoagulation, LAA closure devices could potentially be used. It is also important to note that based on the current recommendations, 9 discontinuation of oral anticoagulation (OAC) after successful ablation is allowed only in patients with a CHA 2 DS 2 -VASc score <2 and that the majority of patients with nonparoxysmal AF that may require LAA electric isolation have a CHA 2 DS 2 -VASc score ≥2.In this issue of the Journal, Panikker et al 21 sought to assess the feasibility, safety, and efficacy of concomitant LAA electric isolation and LAA occlusion with the Watchman closure device in 22 patients undergoing long-standing, persistent AF ablation. Outcomes were compared with a balanced...

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“…The question being left unanswered, even by He et al's study, is whether we should include LAPW isolation in all AF ablation procedures as data has shown PVI-alone is sufficient to eliminate PAF. It seems reasonable to add LAPW isolation on top of PVI if AF has progressed to an advanced stage and the LA has undergone significant remodeling, as in the cases we recently described [5].…”

Section: Rationale Of Performing Lapw Isolationmentioning

confidence: 92%

“…In view of this, it is recommended by the consensus statements that substrate modification should be considered on top of PVs isolation (PVI) in Per AF cases [2]. There is no unique technique of atrial substrate modification while LAPW isolation has been adapted at many centers worldwide and shown to improve the success rate of AF ablation by many isolated studies [3][4][5]. In this issue of JICE, He et al reported their results of a meta-analysis on the efficacy and safety profile of adding LAPW isolation to PVI during AF ablation procedures [6].…”

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confidence: 99%

Left atrial posterior wall isolation: the icing on the cake

Bai

2016

J Interv Card Electrophysiol

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Catheter ablation for symptomatic, drug-resistant atrial fibrillation (AF) has emerged as a promising new therapeutic option over the past decade. Most paroxysmal AF (PAF) is initiated by premature beats from the pulmonary veins (PVs). Therefore, catheter ablation that electrically isolates PVs could abolish the arrhythmia. However, especially in more server cases like persistent or long-standing persistent AF (Per AF), PVs are not the only source and non-PV triggers may arise from any part of the heart but most commonly from the coronary sinus, left atrial posterior wall (LAPW), left atrial appendage (LAA), and superior vena cava (SVC) [1]. These structures also serve as substrates to maintain AF episodes after they start. In view of this, it is recommended by the consensus statements that substrate modification should be considered on top of PVs isolation (PVI) in Per AF cases [2]. There is no unique technique of atrial substrate modification while LAPW isolation has been adapted at many centers worldwide and shown to improve the success rate of AF ablation by many isolated studies [3][4][5]. In this issue of JICE, He et al. reported their results of a meta-analysis on the efficacy and safety profile of adding LAPW isolation to PVI during AF ablation procedures [6]. Five studies with 594 AF patients were included, and the pooled data clearly showed that LAPW isolation reduces atrial tachyarrhythmia recurrence with comparable procedure-related complications and procedural time associated with PVI-alone strategy. Although sample size is small compared to other AF-related trials, this study included the largest series of AF patients treated with LAPW isolation + PVI strategy and provided solid evidence favoring this approach. Before data from a large-scale randomized controlled clinical trial become available, He et al.'s paper can potentially represent a reference for this topic.

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Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation

Abstract: "Outcome of Atrial Fibrillation Ablation After Permanent Pulmonary Vein Antrum Isolation With or Without Proven Left Atrial Posterior Wall Isolation" (LIBERATION). ClinicalTrials.gov Identifier: NCT01660100.

Cited by 156 publications

References 28 publications

Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Pulmonary Vein Antral Isolation and Nonpulmonary Vein Trigger Ablation Are Sufficient to Achieve Favorable Long-Term Outcomes Including Transformation to Paroxysmal Arrhythmias in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Left Atrial Appendage After Electrical Isolation

Left atrial posterior wall isolation: the icing on the cake

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