Segmental ostial catheter ablation (SOCA) to isolate the pulmonary veins (PVs) and left atrial catheter ablation (LACA) to encircle the PVs both may eliminate paroxysmal atrial fibrillation (PAF). ...The relative efficacy of these 2 techniques has not been directly compared.
Of 80 consecutive patients with symptomatic PAF (age, 52+/-10 years), 40 patients underwent PV isolation by SOCA and 40 patients underwent LACA to encircle the PVs. During SOCA, ostial PV potentials recorded with a ring catheter were targeted. LACA was performed by encircling the left- and right-sided PVs 1 to 2 cm from the ostia and was guided by an electroanatomic mapping system; ablation lines also were created in the mitral isthmus and posterior left atrium. The mean procedure and fluoroscopy times were 156+/-45 and 50+/-17 minutes for SOCA and 149+/-33 and 39+/-12 minutes for LACA, respectively. At 6 months, 67% of patients who underwent SOCA and 88% of patients who underwent LACA were free of symptomatic PAF when not taking antiarrhythmic drug therapy (P=0.02). Among the variables of age, sex, duration and frequency of PAF, ejection fraction, left atrial size, structural heart disease, and the ablation technique, only an increased left atrial size and the SOCA technique were independent predictors of recurrent PAF. The only complication was left atrial flutter in a patient who underwent LACA.
In patients undergoing catheter ablation for PAF, LACA to encircle the PVs is more effective than SOCA.
Catheter ablation encircling the pulmonary veins where they enter the left atrium was evaluated in patients with chronic atrial fibrillation. The procedure maintained sinus rhythm for one year in ...three quarters of the patients. Both symptoms and the diameter of the left atrium decreased. Catheter ablation is a viable option in patients with symptomatic, chronic atrial fibrillation.
Catheter ablation maintained sinus rhythm for one year in three quarters of the patients. Both symptoms and the diameter of the left atrium decreased.
Circumferential pulmonary-vein ablation is reported to be effective for paroxysmal and chronic atrial fibrillation.
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However, patients with chronic atrial fibrillation typically receive temporary antiarrhythmic-drug therapy after ablation and often require one or more cardioversions to restore sinus rhythm. These are confounding variables that may inflate the efficacy of catheter ablation. Furthermore, prior studies have not systematically monitored patients for asymptomatic recurrences of atrial fibrillation on a frequent basis. Therefore, we conducted a randomized, controlled study to determine the long-term efficacy of circumferential pulmonary-vein ablation in patients with chronic atrial fibrillation while taking into account the confounding variables of antiarrhythmic-drug . . .
Objectives This study sought to determine whether ablation of complex fractionated atrial electrograms (CFAEs) after antral pulmonary vein isolation (APVI) further improves the clinical outcome of ...APVI in patients with long-lasting persistent atrial fibrillation (AF). Background Ablation of CFAEs has been reported to eliminate persistent AF. However, residual pulmonary vein arrhythmogenicity is a common mechanism of recurrence. Methods In this randomized study, 119 consecutive patients (mean age 60 ± 9 years) with long-lasting persistent AF underwent APVI with an irrigated-tip radiofrequency ablation catheter. Antral pulmonary vein isolation resulted in termination of AF in 19 of 119 patients (Group A, 16%). The remaining 100 patients who still were in AF were randomized to no further ablation and underwent cardioversion (Group B, n = 50) or to ablation of CFAEs in the left atrium or coronary sinus for up to 2 additional hours of procedure duration (Group C, n = 50). Results Atrial fibrillation terminated during ablation of CFAEs in 9 of 50 patients (18%) in Group C. At 10 ± 3 months after a single ablation procedure, 18 of 50 (36%) in Group B and 17 of 50 (34%) in Group C were in sinus rhythm without antiarrhythmic drugs (p = 0.84). In Group A, 15 of 19 patients (79%) were in sinus rhythm. A repeat ablation procedure was performed in 34 of 100 randomized patients (for AF in 30 and atrial flutter in 4). At 9 ± 4 months after the final procedure, 34 of 50 (68%) in Group B and 30 of 50 (60%) in Group C were in sinus rhythm without antiarrhythmic drugs (p = 0.40). Conclusions Up to 2 h of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF.
The pulmonary veins (PVs) have been demonstrated to often play an important role in generating atrial fibrillation (AF). The purpose of this study was to determine the safety and efficacy of ...segmental PV isolation in patients with paroxysmal or persistent AF.
In 70 consecutive patients (mean age, 53 +/- 11 years) with paroxysmal (58) or persistent (12) AF, segmental PV isolation guided by ostial PV potentials was performed. The left superior, left inferior, and right superior PVs were targeted for isolation in all patients, and the right inferior PV was isolated in 20 patients. Among the 230 targeted PVs, 217 (94%) were completely isolated, with a mean of 6.5 +/- 4.2 minutes of radiofrequency energy applied at a maximum power setting of 35 W. A second PV isolation procedure was performed in 6 patients (9%). At 5 months of follow-up, 70% of patients with paroxysmal and 22% of patients with persistent AF were free from recurrent AF (P<0.001), and 83% of patients with paroxysmal AF were either free of symptomatic AF or had significant improvement. Among various clinical characteristics, only paroxysmal AF was an independent predictor of freedom from recurrence of AF (P<0.05). One patient developed unilateral quadrantopsia after the procedure. There were no other complications.
With a segmental isolation approach that targets at least 3 PVs, a clinically satisfactory result can be achieved in >80% of patients with paroxysmal AF. The clinical efficacy of pulmonary vein isolation is much lower when AF is persistent than when it is paroxysmal.
During left atrial (LA) catheter ablation, an atrioesophageal fistula can develop as a result of thermal injury of the esophagus during ablation along the posterior LA. No in vivo studies have ...examined the relationship of the esophagus to the LA. The purpose of this study was to describe the topographic anatomy of the esophagus and the posterior LA by use of CT.
A helical CT scan of the chest with 3D reconstruction was performed in 50 patients (mean age, 54+/-11 years) with atrial fibrillation before an ablation procedure. Consecutive axial and sagittal sections of the CT scan were examined to determine the relationship, size, and thickness of the tissue layers between the LA and the esophagus. The mean length and width of the esophagus in contact with the posterior LA were 58+/-14 and 13+/-6 mm, respectively. The esophagus had a variable course along the posterior LA. The esophagus was close (10+/-6 mm from the ostia) and parallel to the left-sided pulmonary veins (PVs) in 56% of patients and had an oblique course from the left superior PV to the right inferior PV in 36% of patients. The mean thicknesses of the posterior LA and anterior esophageal walls were 2.2+/-0.9 and 3.6+/-1.7 mm, respectively. In 98% of patients, there was a fat layer between the esophagus and the posterior LA. However, this layer was often discontinuous.
The esophagus and posterior LA wall are in close contact over a large area that may often lie within the atrial fibrillation ablation zone, and there is marked variation in the anatomic relationship of the esophagus and the posterior LA. Both the esophageal and atrial walls are quite thin. However, a layer of adipose tissue may serve to insulate the esophagus from thermal injury, explaining why atrioesophageal fistulas are rare.
In patients with atrial fibrillation (AF), the risk of thromboembolic events (TEs) is variable and is influenced by the presence and number of comorbid conditions. The effect of percutaneous left ...atrial radiofrequency ablation (LARFA) of AF on the risk of TEs is unclear.
LARFA was performed in 755 consecutive patients with paroxysmal (n = 490) or chronic (n = 265) AF. Four hundred eleven patients (56%) had > or = 1 risk factor for stroke. All patients were anticoagulated with warfarin for > or = 3 months after LARFA. A TE occurred in 7 patients (0.9%) within 2 weeks of LARFA. A late TE occurred 6 to 10 months after ablation in 2 patients (0.2%), 1 of whom still had AF, despite therapeutic anticoagulation in both. Among 522 patients who remained in sinus rhythm after LARFA, warfarin was discontinued in 79% of 256 patients without risk factors and in 68% of 266 patients with > or = 1 risk factor. Patients older than 65 years or with a history of stroke were more likely to remain anticoagulated despite a successful outcome from LARFA. None of the patients in whom anticoagulation was discontinued had a TE during 25 +/- 8 months of follow-up.
The risk of a TE after LARFA is 1.1%, with most events occurring within 2 weeks after the procedure. Discontinuation of anticoagulant therapy appears to be safe after successful LARFA, both in patients without risk factors for stroke and in patients with risk factors other than age > 65 years and history of stroke. Sufficient safety data are as yet unavailable to support discontinuation of anticoagulation in patients older than 65 years or with a history of stroke.
Movement of the Esophagus During Left Atrial Catheter Ablation for Atrial Fibrillation
Eric Good, Hakan Oral, Kristina Lemola, Jihn Han, Kamala Tamirisa, Petar Igic, Darryl Elmouchi, David Tschopp, ...Scott Reich, Aman Chugh, Frank Bogun, Frank Pelosi, Jr, Fred Morady
In 51 patients with atrial fibrillation, the movement of the esophagus was assessed by digital cine-fluoroscopy after ingestion of barium paste before and after a left atrial catheter ablation procedure. In 67% of the patients, the esophagus moved along the posterior left atrium by ≥2 cm, and in 4% there was a ≥4-cm shift. The width of the esophagus also changed throughout the procedure by 5 ± 7 mm (range = 0 to 36 mm). Because there of movement of the esophagus in a majority of patients during left atrial ablation, real-time imaging of the esophagus is necessary to avoid inadvertent applications of radiofrequency energy close to the esophagus.
The aim of this study was to describe the extent of esophageal mobility that occurs during catheter ablation for atrial fibrillation under conscious sedation.
Ablation along the posterior left atrium may cause an atrioesophageal fistula. One strategy for avoiding this risk is to not deliver radiofrequency energy at sites in contact with the esophagus.
In 51 consecutive patients with atrial fibrillation who underwent left atrial ablation under conscious sedation, digital cine-fluoroscopic imaging of the esophagus was performed in two views after ingestion of barium paste at the beginning and end of the ablation procedure. Movement of the esophagus was determined at the superior, mid-, and inferior parts of the posterior left atrium in reference to the spine.
Mean esophageal movement was 2.0 ± 0.8 cm (range = 0.3 to 3.8 cm) at the superior, 1.7 ± 0.8 cm (range = 0.1 to 3.5 cm) at the mid-, and 2.1 ± 1.2 cm (range = 0.1 to 4.5 cm) at the inferior levels. In 67% of the 51 patients, the esophagus shifted by ≥2 cm, and in 4% there was ≥4 cm of lateral movement. The mean change in esophageal luminal width was 5 ± 7 mm (range = 0 to 36 mm) at the superior, 5 ± 7 mm (range = 0 to 32 mm) at the mid-, and 6 ± 7 mm (range = 0 to 21 mm) at the inferior levels of the posterior left atrium.
The esophagus often is mobile and shifts sideways by ≥2 cm in a majority of patients undergoing catheter ablation for atrial fibrillation under conscious sedation. Therefore, real-time imaging of the esophagus may be helpful in reducing the risk of esophageal injury during radiofrequency ablation along the posterior left atrium.
Radiofrequency catheter ablation of atrial fibrillation (AF) guided by complex fractionated atrial electrograms has been reported to eliminate AF in a large proportion of patients. However, only a ...small number of patients with chronic AF have been included in previous studies.
In 100 patients (mean age, 57+/-11 years) with chronic AF, radiofrequency ablation was performed to target complex fractionated atrial electrograms at the pulmonary vein ostial and antral areas, various regions of the left atrium, and the coronary sinus until AF terminated or all identified complex fractionated atrial electrograms were eliminated. Ablation sites consisted of > or = 1 pulmonary vein in 46% of patients; the left atrial septum, roof, or anterior wall in all; and the coronary sinus in 55%. During 14+/-7 months of follow-up after a single ablation procedure, 33% of patients were in sinus rhythm without antiarrhythmic drugs, 38% had AF, 17% had both AF and atrial flutter, 9% had persistent atrial flutter, and 3% had paroxysmal AF on antiarrhythmic drugs. A second ablation procedure was performed in 44% of patients. Pulmonary vein tachycardia was found in all patients in both previously targeted and nontargeted pulmonary veins. There were multiple macroreentrant circuits in the majority of patients with atrial flutter. At 13+/-7 months after the last ablation procedure, 57% of patients were in sinus rhythm without antiarrhythmic drugs, 32% had persistent AF, 6% had paroxysmal AF, and 5% had atrial flutter.
Modest short-term efficacy is achievable with radiofrequency ablation of chronic AF guided by complex fractionated atrial electrograms, but only after a second ablation procedure in > 40% of patients. Rapid activity in the pulmonary veins and multiple macroreentrant circuits are common mechanisms of recurrent atrial arrhythmias.
Can we trust the force? Pelosi, Frank
Journal of cardiovascular electrophysiology,
February 2023, 2023-02-00, 20230201, Letnik:
34, Številka:
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Journal Article
Because the genesis of atrial fibrillation (AF) is multifactorial and variable, an ablation strategy that involves pulmonary vein isolation and/or a particular set of ablation lines may not be ...equally effective or efficient in all patients with AF. A tailored strategy that targets initiators and drivers of AF is a possible alternative to a standardized lesion set.
Catheter ablation was performed in 153 consecutive patients (mean age, 56+/-11 years) with symptomatic paroxysmal AF with the use of an 8-mm tip radiofrequency ablation catheter. The esophagus was visualized with barium. The pulmonary veins and left atrium were mapped during spontaneous or induced AF. Arrhythmogenic pulmonary veins were isolated or encircled. If AF was still present or inducible, complex electrograms in the left atrium, coronary sinus, and superior vena cava were targeted for ablation. The end point of ablation was absence of frequent atrial ectopy and spontaneous AF during isoproterenol infusion and noninducibility of AF. Routine energy applications near the esophagus were avoided. During follow-up, left atrial flutter developed in 19% of patients and was still present in 10% at >12 weeks of follow-up. A repeat ablation procedure was performed in 18% of patients. During a mean follow-up of 11+/-4 months, 77% of patients were free from AF and/or atrial flutter without antiarrhythmic drug therapy. Pericardial tamponade or transient neurological events occurred in 2% of procedures.
A tailored ablation strategy that only targets triggers and drivers of AF is feasible and eliminates paroxysmal AF in approximately 80% of patients.
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