Pulmonary Vein Isolation Versus Defragmentation

Vogler, Julia; Willems, Stephan; Sultan, Arian; Schreiber, Doreen; Lüker, Jakob; Servatius, Helge; Schäffer, Benjamin; Moser, Julia; Hoffmann, Boris; Steven, Daniel

doi:10.1016/j.jacc.2015.09.088

Cited by 263 publications

(199 citation statements)

References 39 publications

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“…11,15 In our analysis, conversion of AF was not associated with a superior clinical outcome. Of note, we observed only a modest rate (about 60%) of patients in whom AF terminated during ablation, 11 although most of the studies which document a positive influence of AF termination had a higher conversion rate (66%-84%).…”

Section: Conversion Of Af and Arrhythmia Recurrencementioning

confidence: 43%

“…13 The CHASE-AF trial investigated a patient population with mainly persistent AF defined as AF lasting for at least 7 days or a history of DC cardioversion. 11 The median duration of persistent AF in CHASE-AF patients randomized to full defragmentation was 5 months (152 days [65,236] days) and thus significantly shorter than the median AF persistence of 12 months in the present trial. Patients undergoing full defragmentation in CHASE-AF also had smaller mean LA diameters than patients in our Substrate-modification cohort (43.7±5.2 versus 46.7±4.3 mm, respectively).…”

Section: The Substrate-modification Strategy Failed To Reduce Arrhythmentioning

confidence: 48%

“…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.…”

mentioning

confidence: 99%

See 2 more Smart Citations

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

138

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: Conversion Of Af and Arrhythmia Recurrencementioning

confidence: 43%

Section: The Substrate-modification Strategy Failed To Reduce Arrhythmentioning

confidence: 48%

mentioning

confidence: 99%

See 1 more Smart Citation

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

138

105

View full text Add to dashboard Cite

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“…20,22,23 The latter may explain why CFAE ablation has led to conflicting clinical outcomes as reported in the literature. 31,33,34 As occurred in this study, the novel integrated electrophysiological map may allow automated real-time characterization of multiple mechanisms during AF, by identifying regions exhibiting repetitive and regular activities, CV of consistent wave fronts, fragmentation, and electrically silent areas. These findings are relevant as they might characterize the respective contribution of different arrhythmogenic substrates within the pathological AF environment as it might lead to a better understanding of each patient-specific mechanism.…”

Section: Clinical Implications Of Af Driver Ablationmentioning

confidence: 88%

Clinical Outcome of Electrophysiologically Guided Ablation for Nonparoxysmal Atrial Fibrillation Using a Novel Real-Time 3-Dimensional Mapping Technique

Pappone

Ciconte

Vicedomini

et al. 2018

Circ: Arrhythmia and Electrophysiology

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BACKGROUND:Clinical outcomes after ablation of persistent atrial fibrillation remain suboptimal. Identification of AF drivers using a novel integrated mapping technique may be crucial to ameliorate the clinical outcome. METHODS AND RESULTS:Persistent AF patients were prospectively enrolled to undergo high-density electrophysiological mapping to identify repetitive-regular activities (RRas) before modified circumferential pulmonary vein (PV) ablation. They have been randomly assigned (1:1 ratio) to ablation of RRa followed by modified circumferential PV ablation (mapping group; n=41) or modified circumferential PV ablation alone (control group; n=40). The primary end point was freedom from arrhythmic recurrences at 1 year. In total, 81 persistent AF patients (74% male; mean age, 61.7±10.6 years) underwent mapping/ablation procedure. The regions exhibiting RRa were 479 in 81 patients (5.9±2.4 RRa per patient): 232 regions in the mapping group (n=41) and 247 in the control group (n=40). Overall, 185 of 479 (39%) RRas were identified within the PVs, whereas 294 of 479 (61%) in non-PV regions. Mappingguided ablation resulted in higher arrhythmia termination rate when compared with conventional strategy (25/41, 61% versus 12/40, 30%; P<0.007). Total radiofrequency duration (P=0.38), mapping (P=0.46), and fluoroscopy times (P=0.69) were not significantly different between the groups. No major procedure-related adverse events occurred. After 1 year, 73.2% of mapping group patients were free from recurrences versus 50% of control group (P=0.03). CONCLUSIONS:Targeted ablation of regions showing RRa provided an adjunctive benefit in terms of arrhythmia freedom at 1-year follow-up in the treatment of persistent AF. These findings might support a patienttailored strategy in subjects with nonparoxysmal AF and should be confirmed by additional larger, randomized, multicenter studies.

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“…Multiple catheter ablation strategies in addition to PVI have been used to try and increase the efficacy of catheter ablation for the treatment of persistent and long-standing persistent AF [15,[17][18][19]. These additional strategies include the addition of ablation of complex abnormal fractionated electrograms, addition of linear ablation lines, targeting rotors and elimination of ectopic atrial tachycardias and/or atrial flutters [17][18][19][20][21].…”

Section: Introductionmentioning

confidence: 99%

Evolution of Catheter Based Therapies for Persistent and Long-Standing Persistent Atrial Fibrillation: The Amaze Trial

Badhwar¹,

Lee²

2017

Health Care Current Reviews

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Atrial fibrillation (AF) is the most common arrhythmia of man and the incidence of AF increases with age. AF is known to increase the risk of stroke, heart failure and death. Patients with persistent and longstanding persistent AF generally do not respond to medications. Catheter ablation of AF is associated with a high rate of success in patients with paroxysmal AF. However, once a patient develops persistent or longstanding persistent AF, the outcomes of curing AF drop dramatically with catheter ablation. The development of new technologies and procedures has allowed physicians to perform catheter-based procedures that could previously be done only with cardiac surgery. One such technological development is the LARIAT procedure that allows cardiac electrophysiologists and surgeons to percutaneously exclude the left atrial appendage (LAA) and perform catheter ablation resulting in a percutaneous alternative to the open-chested surgical procedure, the Cox-Maze procedure. The AMAZE trial is a prospective, multi-center trial that was designed to evaluate the safety and effectiveness of the LARIAT procedure to percutaneously exclude the LAA; and to determine if LAA exclusion combined with catheter based pulmonary vein isolation improves maintenance of sinus rhythm in patients with persistent or long standing persistent AF. The mini-review will describe the epidemiology of AF, review current treatment of AF and provide the rationale and status for the AMAZE trial.

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Pulmonary Vein Isolation Versus Defragmentation

Cited by 263 publications

References 39 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

Clinical Outcome of Electrophysiologically Guided Ablation for Nonparoxysmal Atrial Fibrillation Using a Novel Real-Time 3-Dimensional Mapping Technique

Evolution of Catheter Based Therapies for Persistent and Long-Standing Persistent Atrial Fibrillation: The Amaze Trial

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