The Electrical Isolation of the Left Atrial Posterior Wall in Catheter Ablation of Persistent Atrial Fibrillation

Lee, Jung Myung; Shim, Jaemin; Park, Junbeom; Yu, Hee Tae; Kim, Tae-Hoon; Park, Jin‐Kyu; Uhm, Jae Sun; Kim, Jin Bae; Joung, Boyoung; Lee, Moon Hyoung; Kim, Young-Hoon; Pak, Hui Nam; Investigators, Pobi-Af

doi:10.1016/j.jacep.2019.08.021

Cited by 131 publications

(132 citation statements)

References 28 publications

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“…We recognize however that there are a limited number of RCTs comparing PVI and PVI + PW in persistent AF, and that removing some of the studies in our analysis during the sensitivity analysis can alter the results significantly. One recent RCT included in our analysis for instance did not find a difference between both techniques 21 . In this study, 50% of the patients who underwent redo ablation had non‐isolated PW.…”

Section: Discussionmentioning

confidence: 45%

“…The longer the duration, the most likely non‐PV triggers will be present and the more altered and scared the atrial substrate might be. In the trial by Lee et al, 21 most patients had long standing persistent AF (77.5%), also patients who underwent PWI had a mean 44 months duration of AF compared with 33 months in the PVI only group ( P = .044). In addition, the ablation technique of the posterior wall might vary in many ways from one patient to another even within the same study.…”

Section: Discussionmentioning

confidence: 90%

“…This meta‐analysis compares the clinical outcomes of patients with persistent AF who underwent PVI alone versus PVI with PWI. We evaluated six studies (two RCTs and four observational studies) that included a total of 1334 patients 16‐21 . To date, this is the largest meta‐analysis evaluating the role of adjunctive PWI specifically in patients with persistent AF.…”

Section: Discussionmentioning

confidence: 99%

“…The randomized control trial ( NCT03057548) comparing pulmonary vein ablation with or without left atrial posterior wall ablation in persistent atrial fibrillation is excluded as trial data has not been released (“PIVoTAL http://ClinicalTrials.gov,” n.d.). Overall, six studies met the inclusion criteria in which two were randomized clinical trials (RCTs) and four were observational studies 16‐21 …”

Section: Methodsmentioning

confidence: 99%

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Clinical outcomes of adjunctive posterior wall isolation in persistent atrial fibrillation: A meta‐analysis

Salih

Darrat²,

Ibrahim

et al. 2020

Cardiovasc electrophysiol

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Background: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation but the recurrence rate remains relatively high in persistent patients with AF. Therefore, posterior wall isolation (PWI) in addition to PVI has been proposed to increase freedom from AF.Objective: To evaluate the success of adjunctive PWI in persistent AF. Methods:We searched electronic database using specific terms. The primary outcomes are recurrence rate of AF and recurrence of atrial arrhythmias. The secondary outcomes were atrial flutter/tachycardia (AFL/AT), procedure time, fluoroscopy time, and procedure related complications. Estimated risk ratios (RRs) and 95% confidence intervals (CIs) were evaluated.Results: Six studies were included (1334 patients with persistent AF). Adjunctive PWI resulted in a significant reduction in the recurrence rate of AF compared with patients who had PVI only (19.8% vs 29.1%; RR, 0.64; 95% CI, 0.42-0.97; P < .04; I 2 = 76%). There was a significant reduction in the recurrence rate of all atrial arrhythmia (30.8% vs 41.1%; RR, 0.75; 95% CI, 0.60-0.94; P < .01; I 2 = 60%). Compared with PVI only, adjunctive PWI did not increase the rate of AFL or AT (11.6% vs 13.9%; RR, 0.85; 95% CI, 0.54-1.32; P < .46; I 2 = 47%) or the rate of procedure related complications (4.6% vs 3.6%; RR, 1.25; 95% CI, 0.72-2.17; P < .44; I 2 = 0%). Conclusion:In patients with persistent AF, adjunctive PWI was associated with decreased recurrence of AF and atrial arrhythmias compared with PVI alone without an increased risk of AFL or AT or procedure related complications. K E Y W O R D Satrial fibrillation, atrial flutter, meta-analysis, posterior wall isolation, pulmonary vein isolation 1 | BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia, with a prevalence of 0.5% to 1% of the population, 1 and is expected to rise even more over the next decades. 2 Historically management of AF has been geared toward rate control, or rhythm control with antiarrhythmic drugs. Over the last two decades, catheter ablation has emerged as an alternative for rhythm control with medications and is now a recognized first line therapy for the treatment of AF in select populations. This is emphasized for instance in the recent American College of Cardiology updated guidelines, which states that catheter ablation may be used in selected patients with symptomatic AF and heart failure with low ejection fraction based on data to support reduced hospitalization and potentially even reduce mortality. 3

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Section: Discussionmentioning

confidence: 45%

Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 2 more Smart Citations

Clinical outcomes of adjunctive posterior wall isolation in persistent atrial fibrillation: A meta‐analysis

Salih

Darrat²,

Ibrahim

et al. 2020

Cardiovasc electrophysiol

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“…Atrial fibrillation (AF) mechanisms are complex and the extent of ablation needed to modulate the rhythm is unclear. 1 While pulmonary vein isolation (PVI) is the cornerstone of AF ablation, the long-term success after PVI for persistent AF is suboptimal. 2,3 Better understanding of how PVI affects persistent AF may offer insight to improve technique, guide patient selection, or target alternative mechanisms.…”

mentioning

confidence: 99%

The interconnected atrium: Acute impact of pulmonary vein isolation on remote atrial tissue

Rogers

Baykaner

Narayan

2020

Cardiovasc electrophysiol

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Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation

Valderrábano

Peterson

Swarup

et al. 2020

JAMA

205

201

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IMPORTANCE Catheter ablation of persistent atrial fibrillation (AF) has limited success. Procedural strategies beyond pulmonary vein isolation have failed to consistently improve results. The vein of Marshall contains innervation and AF triggers that can be ablated by retrograde ethanol infusion. OBJECTIVE To determine whether vein of Marshall ethanol infusion could improve ablation results in persistent AF when added to catheter ablation. DESIGN, SETTING, AND PARTICIPANTS The Vein of Marshall Ethanol for Untreated Persistent AF (VENUS) trial was an investigator-initiated, National Institutes of Health-funded, randomized, single-blinded trial conducted in 12 centers in the United States. Patients (N = 350) with persistent AF referred for first ablation were enrolled from October 2013 through June 2018. Follow-up concluded in June 2019. INTERVENTIONS Patients were randomly assigned to catheter ablation alone (n = 158) or catheter ablation combined with vein of Marshall ethanol infusion (n = 185) in a 1:1.15 ratio to accommodate for 15% technical vein of Marshall ethanol infusion failures. MAIN OUTCOMES AND MEASURESThe primary outcome was freedom from AF or atrial tachycardia for longer than 30 seconds after a single procedure, without antiarrhythmic drugs, at both 6 and 12 months. Outcome assessment was blinded to randomization treatment. There were 12 secondary outcomes, including AF burden, freedom from AF after multiple procedures, perimitral block, and others. RESULTSOf the 343 randomized patients (mean [SD] age, 66.5 [9.7] years; 261 men), 316 (92.1%) completed the trial. Vein of Marshall ethanol was successfully delivered in 155 of 185 patients. At 6 and 12 months, the proportion of patients with freedom from AF/atrial tachycardia after a single procedure was 49.2% (91/185) in the catheter ablation combined with vein of Marshall ethanol infusion group compared with 38% (60/158) in the catheter ablation alone group (difference, 11.2% [95% CI, 0.8%-21.7%]; P = .04). Of the 12 secondary outcomes, 9 were not significantly different, but AF burden (zero burden in 78.3% vs 67.9%; difference, 10.4% [95% CI, 2.9%-17.9%]; P = .01), freedom from AF after multiple procedures (65.2% vs 53.8%; difference, 11.4% [95% CI, 0.6%-22.2%]; P = .04), and success achieving perimitral block (80.6% vs 51.3%; difference, 29.3% [95% CI, 19.3%-39.3%]; P < .001) were significantly improved in vein of Marshall-treated patients. Adverse events were similar between groups.CONCLUSIONS AND RELEVANCE Among patients with persistent AF, addition of vein of Marshall ethanol infusion to catheter ablation, compared with catheter ablation alone, increased the likelihood of remaining free of AF or atrial tachycardia at 6 and 12 months. Further research is needed to assess longer-term efficacy.

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The Electrical Isolation of the Left Atrial Posterior Wall in Catheter Ablation of Persistent Atrial Fibrillation

Cited by 131 publications

References 28 publications

Clinical outcomes of adjunctive posterior wall isolation in persistent atrial fibrillation: A meta‐analysis

Clinical outcomes of adjunctive posterior wall isolation in persistent atrial fibrillation: A meta‐analysis

The interconnected atrium: Acute impact of pulmonary vein isolation on remote atrial tissue

Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation

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