Role of the Posterior Left Atrium and Pulmonary Veins in Human Lone Atrial Fibrillation

Todd, Derick; Skanes, Allan C.; Guiraudon, G; Guiraudon, C; Krahn, Andrew D.; Yee, Raymond; Klein, George J.

doi:10.1161/01.cir.0000104567.72914.bf

Cited by 138 publications

(30 citation statements)

References 41 publications

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“…These data are consistent with a recent surgical study that showed that recurrent PAF was due to an incomplete circular lesion and could be cured by closing the gap in the previous CCL in 1 patient. 13 These data strongly support the hypothesis that it is necessary to isolate all PVs to prevent recurrence. Of course, this hypothesis can only be proven when all patients, including asymptomatic patients, undergo a control study.…”

Section: Clinical Outcome and Recurrent Atrial Tachyarrhythmias Aftersupporting

confidence: 68%

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Complete Isolation of Left Atrium Surrounding the Pulmonary Veins

et al. 2004

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Background-Paroxysmal atrial fibrillation (PAF) can be eliminated with continuous circular lesions (CCLs) around the pulmonary veins (PVs), but it is unclear whether all PVs are completely isolated. Methods and Results-Forty-one patients with symptomatic PAF underwent 3D mapping, and all PV ostia were marked on the 3D map based on venography. Irrigated radiofrequency energy was applied at a distance from the PV ostia guided by 2 Lasso catheters placed within the ipsilateral superior and inferior PVs. The mean radiofrequency duration was 1550Ϯ511 seconds for left-sided PVs and 1512Ϯ506 seconds for right-sided PVs. After isolation, automatic activity was observed in the right-sided PVs in 87.8% and in the left-sided PVs in 80.5%. During the procedure, a spontaneous or induced PV tachycardia (PVT) with a cycle length of 189Ϯ29 ms was observed in 19 patients. During a mean follow-up of 6 months, atrial tachyarrhythmias recurred in 10 patients. Nine patients underwent a repeat procedure. Conduction gaps in the left CCL in 9 patients and in the right CCL in 2 patients were closed during the second procedure. A spontaneous PVT with a cycle length of 212Ϯ44 ms was demonstrated in 7 of 9 patients, even though no PVT had been observed in 6 of these 7 patients during the first procedure. No AF recurred in 39 patients after PV isolation during follow-up. Conclusions-Automatic activity and fast tachycardia within the PVs could reflect an arrhythmogenic substrate in patients with PAF, which could be eliminated by isolating all PVs with CCLs guided by 3D mapping and the double-Lasso technique in the majority of patients.

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Section: Clinical Outcome and Recurrent Atrial Tachyarrhythmias Aftersupporting

confidence: 68%

“…The simultaneous use of 2 Lasso catheters gives insights into the electrical interactions of the ipsilateral PVs and helps identify conduction gaps in the CCL after intravenous administration of adenosine and in recurrent arrhythmias after CCL. 12,13 …”

Section: Pv Isolation By Ccls In the Lamentioning

confidence: 99%

Complete Isolation of Left Atrium Surrounding the Pulmonary Veins

et al. 2004

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“…They found evidence of repetitive activation during AF in the LA and concluded that the LA was the driver of AF in the majority of patients. In a recent surgical study, Todd and colleagues 15 performed total surgical isolation of the PVs and posterior LA/PV region in 14 patients with chronic AF. They showed that posterior LA isolation led to isolated AF in the isolated PV region in 4 patients and cured AF in all 14 patients after a mean of 25 months of follow-up, which highlights the importance of the posterior LA/PV region in maintaining AF.…”

Section: Discussionmentioning

confidence: 99%

Presence of Left-to-Right Atrial Frequency Gradient in Paroxysmal but Not Persistent Atrial Fibrillation in Humans

et al. 2004

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Background— Recent studies have demonstrated spatiotemporal organization in atrial fibrillation (AF), with a left-to-right atrial frequency gradient during AF in isolated sheep hearts. We hypothesized that human AF would also manifest a left-to-right atrial frequency gradient. Methods and Results— Thirty-one patients aged 56.7±10.5 years with a history of paroxysmal or persistent (>1 month) AF were included. Recordings were made at each pulmonary vein (PV) ostium and simultaneously from the coronary sinus (CS) and posterior right atrium (RA) during AF. Sequential fast Fourier transforms (FFTs) were performed. FFT profiles were analyzed to determine the dominant frequency (DF). There were 18 patients with paroxysmal AF and 13 with persistent AF. In the paroxysmal group, there was a significant left-to-right atrial DF gradient, with DF highest at the PV/left atrial (LA) junction, intermediate at the CS, and lowest in the RA (6.2±0.8, 5.5±0.7, and 5.1±0.6 Hz, respectively; P <0.001). There were no patients in whom DF was greater at the RA than the PV/LA junction. In the persistent group, there was no significant difference between DF recorded from the LA/PV junction, CS, and RA (6.1±0.7, 5.8±0.6, and 5.8±0.6 Hz, respectively; P =NS). Conclusions— In humans with paroxysmal AF, DFs are highest at the PV/LA junction, intermediate in the CS, and slowest in the posterior RA. These findings agree with animal models that suggest that the posterior LA may play an important role in maintaining paroxysmal AF. The role of the posterior LA in persistent AF requires further study.

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“…The incorporated PVs form the smooth posterior wall of the LA, while the trabeculated portion of the LA comes to occupy a more ventral aspect [7,8]. Anatomically, there is an abrupt change in LA subendocardial fiber orientation as this bundle traverses the posterior LA between the PVs, which create a basis of reentry [9,10]. Indeed, previous work using noncontact mapping has demonstrated significant conduction abnormalities in the posterior LA during sinus rhythm in patients with PAF [9].…”

Section: Rationale Of Performing Lapw Isolationmentioning

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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Role of the Posterior Left Atrium and Pulmonary Veins in Human Lone Atrial Fibrillation

Cited by 138 publications

References 41 publications

Complete Isolation of Left Atrium Surrounding the Pulmonary Veins

Complete Isolation of Left Atrium Surrounding the Pulmonary Veins

Presence of Left-to-Right Atrial Frequency Gradient in Paroxysmal but Not Persistent Atrial Fibrillation in Humans

Left atrial posterior wall isolation: the icing on the cake

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