scholarly journals Beyond pulmonary vein isolation for persistent atrial fibrillation: sequential high-resolution mapping to guide ablation

Author(s):  
Katarzyna Malaczynska-Rajpold ◽  
Julian Jarman ◽  
Rui Shi ◽  
Piers Wright ◽  
Tom Wong ◽  
...  

Abstract Purpose We aimed to evaluate whether outcomes with ablation in persistent (PsAF) and long-standing persistent (LsPsAF) AF can be improved beyond what can be achieved with pulmonary vein isolation (PVI) alone, using individualized mapping to guide ablation. Methods We studied 20 pts (15 M, 68 ± 11y) with PsAF (14) or LsPsAF (6) referred for first-time AF ablation. Following antral PVI, individualized mapping (IM) was performed using a high-density mapping catheter stably and fully deployed for 30 s at each of 23 ± 9 sites per patient. Activation data were reviewed, and an ablation strategy designed to intersect areas of focal and rotational activity. Mean follow-up was 429 ± 131 days. The study population was compared to a matched contemporary control cohort (CC) of 20 consecutive patients undergoing conventional ablation. Results Despite the IM group having a higher median comorbidities score, 3.5 vs. 2.5 in the CC group, indicating potentially more complex patients and more advanced substrate, cumulative freedom from AF after a single procedure was achieved in 94% of patients in the IM group vs. 75% in the CC group at 1 year and remained the same in both groups at the conclusion of the study (p = 0.02). There was a similar trend in atrial arrhythmia-free survival between both groups (84% vs. 67% at 1 year) that did not reach statistical significance. The procedure duration was longer in the IM group by a median of 31.5 min (p = 0.004). Conclusions Individualized mapping to guide AF ablation appears to achieve significantly greater AF-free survival compared to conventional PVI when applied as a primary ablation treatment. The results of this pilot study need to be confirmed in a larger, randomized trial.

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Dan L Musat ◽  
Nicolle S Milstein ◽  
Jacqueline Pimienta ◽  
Advay Bhatt ◽  
Tina C Sichrovsky ◽  
...  

Background: Pulmonary vein isolation (PVI) is a cornerstone of atrial fibrillation (AF) ablation procedures to treat symptomatic AF. Ablation success is defined by absence of AF recurrence >30 seconds. However, reduction in AF burden (AFB) is also an important endpoint. Whether patients with paroxysmal (PAF) and persistent AF (PeAF) have similar reduction in AFB post-ablation is unknown. Objective: To compare the decrease in AFB following cryoballoon (CB) PVI in patients with PAF and PeAF. Methods: We enrolled consecutive pts with an implantable loop recorder (ILR) who subsequently underwent CB PVI. All patients were followed prospectively for at least one year, or until repeat ablation; we compared AFB pre and post-ablation. Results: The cohort included had 47 patients (66 ± 10 years; 32 [68%] male; PAF [n=23, 49%]; CHA 2 DS 2 -VASc 2.7 ± 1.7, 34 [72%] on AAD at the time of ablation). A median of 136 days [IQR 280, 73; minimum of 30 days] of ILR data pre-ablation were available. The median AFB for PAF was 4.7% [IQR 0.9, 14.8] and PeAF was 6.8% [IQR 1.1, 40.4]. After excluding a 3-month post-ablation blanking period, recurrent AF occurred in 12 (52%) PAF and 11 (46%) PeAF patients. The median AFB post-ablation for PAF and PeAF cohorts was 0.03%, [IQR 0, 0.3] and 0.04%, [IQR 0, 1.1], respectively. This represents a >99% reduction in AFB. Conclusion: Although 50% of patients undergoing CB PVI for PAF or PeAF had a recurrence of AF, there was >99% reduction in AFB in both groups. These data highlight the importance of using AFB burden as a marker of therapeutic efficacy post-AF ablation.


Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Emily Guhl ◽  
Donald Siddoway ◽  
Evan Adelstein ◽  
Samir Saba ◽  
Andrew Voigt ◽  
...  

Introduction: Cryoballoon pulmonary vein isolation (PVI) has emerged as an alternative to radiofrequency PVI for the treatment of paroxysmal atrial fibrillation (AF). The optimal ablation strategy for patients with persistent AF is unclear, as data on Cryoballoon PVI alone are limited. Methods: We analyzed a prospective registry of consecutive patients with persistent AF who underwent Cryoballoon PVI at a single center between 2011 and 2014. Patients were assessed for AF recurrence (including any atrial arrhythmia) after a 3 month blanking period at 6 months, 1 year, 2 years, and as needed for symptoms post PVI. Recurrence was based on typical symptoms or ECG/ event monitor evidence of AF. Kaplan-Meier analysis was used to estimate AF-free survival. Results: The 69 patients who underwent Cryoballoon PVI were aged 59 ± 8 years, 86% male, 54% HTN, had a CHADS2-VASC score 1.6 ± 1.2, and had a LA dimension 4.5 ± 0.6 cm. The AF recurrence-free rate at 1-year post-procedure was 59%. Overall, AF-free survival was 50% at the mean follow-up of 607 days. In comparing patients with persistent AF duration <1 year vs. >1 year, there was a trend toward greater AF recurrence-free rates in the <1 year group (66% vs 55%, p=0.09) Conclusions: Cryoballoon PVI appears to be an effective initial strategy in treating persistent AF, with an AF recurrence-free rate of 59% at 1 year.


2021 ◽  
Vol 17 ◽  
Author(s):  
Ikechukwu Ifedili ◽  
Kristina Mouksian ◽  
David Jones ◽  
Ibrahim El Masri ◽  
Mark Heckle ◽  
...  

: Atrial fibrillation (AF) is the most common form of electrical disturbance of the heart and contributes to significant patient morbidity and mortality. With better understanding of the mechanisms of atrial fibrillation and improvements in mapping and ablation technologies, ablation has become a preferred therapy for patients with symptomatic AF. Pulmonary vein isolation (PVI) is the cornerstone for AF ablation therapy, but particularly in patients with AF occurring for longer than 7 days (persistent AF), identifying clinically significant non pulmonary vein targets and achieving durability of ablation lesions remain an important challenge.


Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Markus Rottmann ◽  
Shin Yoo ◽  
Anna Pfenniger ◽  
David Johnson ◽  
Gail Elizabeth Geist ◽  
...  

Introduction: Pulmonary vein isolation (PVI) is thought to be efficacious in patients with paroxysmal and persistent atrial fibrillation (AF). However, the underlying mechanisms by which PVI leads to beneficial atrial remodeling are not clear. Hypothesis: We hypothesized that PVI leads to beneficial atrial remodeling by affecting electrophysiological characteristics at sites ‘remote’ from the site of ablation. We examined the effect of PVI on stability of rotational activity throughout both atria. Methods: AF was induced in 12 dogs by rapid atrial pacing for 3-6 weeks. PVI was performed in 3 dogs, 9 dogs were used as controls. Epicardial high-density mapping was performed (117 electrodes, inter-elec. distance 2.5mm) before and after PVI. The AF characteristics were analyzed in 6 regions in the left (LA) and right atrium (RA): Cycle length (CL), stability, number of observed rotational activities based on local activation time (LAT) maps. Results: Multiple interacting rotational activities were detected in all regions with highest stability in the appendages (Figure A). PVI led to a significant increase in CL (range: 2.26 %-14.1%) in all regions (Figure B). Stability of rotational activity decreased (baseline vs after PVI) in all atrial regions: LAA (594±344ms, median 525ms vs 354±126ms, median 300ms), PLA (564±491ms, median 360ms vs 180±25ms, median 180ms), LAFW (323±248ms, median 240ms vs 240±70ms, median 240ms), in PRA (260±1167ms, median 210ms vs 239±75ms, median 240ms), RAA (1521±1301ms, median 975ms vs 457±251ms, median 450ms), P<=0.05 for all comparisons, RAFW (1521±1301ms, median 975ms vs 457±251ms, median 450ms, P=0.46) (Figure C). PVI reduced number of observed rotational activities by 25.76% in all regions (P>0.5). Conclusions: PVI significantly reduces the stability of rotational drivers in atrial regions remote from the site of ablation. We believe we have discovered a new mechanism by which PVI leads to beneficial remodeling in both the LA and RA.


2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Di Cori ◽  
L Segreti ◽  
G Zucchelli ◽  
S Viani ◽  
F Tarasco ◽  
...  

Abstract Background Contact force catheter ablation is the gold standard for treatment of atrial fibrillation (AF). Local tissue impedance (LI) evaluation has been recently studied to evaluate lesion formation during radiofrequency ablation. Purpose Aim of the study was to assess the outcomes of an irrigated catether with LI alghorithm compared to contact force (CF)-sensing catheters in the treatment of symptomatic AF. Methods A prospective, single-center, nonrandomized study was conducted, to compare outcomes between CF-AF ablation (Group 1) and LI-AF ablation (Group 2). For Group 1 ablation was performed using the Carto 3© System with the SmartTouch SF catheter and, as ablation target, an ablation index value of 500 anterior and 400 posterior. For Group 2, ablation was performed using the Rhythmia™ System with novel ablation catheter with a dedicated algorithm (DirectSense) used to measure LI at the distal electrode of this catheter. An absolute impedance drop greater than 20Ω was used at each targeted. According to the Close Protocol, ablation included a point by point pulmonary vein isolation (PVI) with an Inter-lesion space ≤5 mm in both Groups. Procedural endpoint was PVI, with confirmed bidirectional block. Results A total of 116 patients were enrolled, 59 patients in Group 1 (CF) and 57 in Group 2 (LI), 65 (63%) with a paroxismal AF and 36 (37%) with a persistent AF. Baseline patients features were not different between groups (P=ns). LI-Group showed a comparable procedural time (180±89 vs 180±56, P=0.59) but with a longer fluoroscopy time (20±12 vs 13±9 min, P=0.002). Wide antral isolation was more often observed in CF-Group (95% vs 80%, P=0.022), while LI-Group 2 required frequently additional right or left carina ablation (28% vs 14%, P=0.013). The mean LI was 106±14Ω prior to ablation and 92.5±11Ω after ablation (mean LI drop of 13.5±8Ω) during a median RF time of 26 [19–34] sec for each ablation spot. No steam pops or complications during the procedures were reported. The acute procedural success was 100%, with all PVs successfully isolated in all study patients. Regarding safety, only minor vascular complications were observed (5%), without differences between groups (p=0.97). During follow up, 9-month freedom from atrial fibrillation/atrial flutter/atrial tachycardia recurrence was 86% in Group 1 and 75% in Group 2 (P=0.2). Conclusions An LI-guided PV ablation strategy seems to be safe and effective, with acute and mid-term outcomes comparable to the current contact force strategy. LI monitoring could be a promising complementary parameter to evaluate not only wall contact but also lesion formation during power delivery. Procedural Outcomes Funding Acknowledgement Type of funding source: None


2013 ◽  
Vol 106 (10) ◽  
pp. 501-510 ◽  
Author(s):  
Frederic A. Sebag ◽  
Najia Chaachoui ◽  
Nick W. Linton ◽  
Sana Amraoui ◽  
James Harrison ◽  
...  

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