Multicenter study of novel mapping technique to detect non-pulmonary vein triggers excluding the origin from left atrial posterior wall and superior vena cava

Abstract Background It has been reported that elimination of non-pulmonary vein (PV) triggers after PV isolation is a good predictor of atrial tachyarrhythmia free survival. However, precise mapping of triggers outside from superior vena cava (SVC) or left atrial posterior wall (LAPW) are difficult. The aim of this study is to assess the efficacy of self-reference mapping technique to eliminate non-PV triggers originated from outside of primordial pulmonary vein area. Methods Total of 431 patients (446 procedures) underwent atrial fibrillation (AF) ablation in a hospital and in a medical center from January 2017 to March 2019. After isolation of PV, non-PV triggers were induced with isoproterenol and/or adenosine triphosphate. Reproducible non-PV triggers were targeted to ablate using following self-reference mapping technique: A trigger conducts centrifugally and the earliest site should be distinguished from other later activated sites. Using a PentaRay multipolar catheter, the operators annotated the earliest site of local activation and a reference tag was placed. The multipolar catheter was then moved to the reference tag and the process repeated. Ultimately, we identified clusters of early circumferential activation and ablated. Results A total of 32 non-PV triggers excluding the origin from LAPW and SVC were induced in 23 patients. Nineteen triggers (59%) were located in the right atrium and 13 triggers (41%) in the left atrium (Figure 1). All triggers were eliminated with ablation and AF was non-inducible in all patients at the end of the procedure. During the follow-up (529±270 days), 18 patients (77%) were free from atrial tachyarrhythmias after a 3-month blanking period. Three patients received additional ablation procedures for recurrent atrial arrhythmias. No non-PV triggers ablated during the previous procedure were observed. Conclusion A novel self-reference mapping technique is useful for eliminating non-PV triggers in terms of the short- and long-term success. Figure 1. Distribution of non-PV triggers Funding Acknowledgement Type of funding source: None

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Natural History of Arrhythmia After Successful Isolation of Pulmonary Veins, Left Atrial Posterior Wall, and Superior Vena Cava in Patients With Paroxysmal Atrial Fibrillation: A Multi‐Center Experience

Journal of the American Heart Association ◽

10.1161/jaha.120.020563 ◽

2021 ◽

Author(s):

Sanghamitra Mohanty ◽

Chintan Trivedi ◽

Pamela Horton ◽

Domenico G. Della Rocca ◽

Carola Gianni ◽

...

Keyword(s):

Atrial Fibrillation ◽

Superior Vena Cava ◽

Paroxysmal Atrial Fibrillation ◽

Left Atrial ◽

Superior Vena ◽

Pulmonary Veins ◽

Vena Cava ◽

Posterior Wall ◽

Left Atrial Posterior ◽

Group 1

Background We evaluated long‐term outcome of isolation of pulmonary veins, left atrial posterior wall, and superior vena cava, including time to recurrence and prevalent triggering foci at repeat ablation in patients with paroxysmal atrial fibrillation with or without cardiovascular comorbidities. Methods and Results A total of 1633 consecutive patients with paroxysmal atrial fibrillation that were arrhythmia‐free for 2 years following the index ablation were classified into: group 1 (without comorbidities); n=692 and group 2 (with comorbidities); n=941. We excluded patients with documented ablation of areas other than pulmonary veins, the left atrial posterior wall, and the superior vena cava at the index procedure. At 10 years after an average of 1.2 procedures, 215 (31%) and 480 (51%) patients had recurrence with median time to recurrence being 7.4 (interquartile interval [IQI] 4.3–8.5) and 5.6 (IQI 3.8–8.3) years in group 1 and 2, respectively. A total of 201 (93.5%) and 456 (95%) patients from group 1 and 2 underwent redo ablation; 147/201 and 414/456 received left atrial appendage and coronary sinus isolation and 54/201 and 42/456 had left atrial lines and flutter ablation. At 2 years after the redo, 134 (91.1%) and 391 (94.4%) patients from group 1 and 2 receiving left atrial appendage/coronary sinus isolation remained arrhythmia‐free whereas sinus rhythm was maintained in 4 (7.4%) and 3 (7.1%) patients in respective groups undergoing empirical lines and flutter ablation ( P <0.001). Conclusions Very late recurrence of atrial fibrillation after successful isolation of pulmonary veins, regardless of the comorbidity profile, was majorly driven by non‐pulmonary vein triggers and ablation of these foci resulted in high success rate. However, presence of comorbidities was associated with significantly earlier recurrence.

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Five-box thoracoscopic maze based on the Gemini-S bipolar ablation device to treat atrial fibrillation

10.1510/mmcts.2021.054 ◽

2021 ◽

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Superior Vena ◽

Pulmonary Veins ◽

Vena Cava ◽

Posterior Wall ◽

Left Atrial Appendage Closure ◽

Electrophysiological Effects ◽

Left Atrial Posterior

Thoracoscopic atrial fibrillation ablation seeks to replicate the electrophysiological effects of more invasive, open surgical procedures. The authors present a lesion concept that includes isolation of the pulmonary veins, the left atrial posterior wall, and the superior vena cava, respectively, lines to inhibit perimitral and periauricular flutter circuits, and left atrial appendage closure. All lesions are tested for bidirectional block.

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The impact of an empiric superior vena cava isolation added to pulmonary vein isolation for non-paroxysmal atrial fibrillation associated with left atrial low voltage areas

European Heart Journal ◽

10.1093/ehjci/ehaa946.0578 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

T Omuro ◽

Y Yoshiga ◽

M Fukuda ◽

T Kato ◽

S Fujii ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Superior Vena Cava ◽

Left Atrial ◽

Low Voltage ◽

Superior Vena ◽

Vena Cava ◽

Free Survival ◽

Initial Session ◽

The Impact

Abstract Introduction Left atrial low-voltage areas (LVAs) are associated with recurrence after radiofrequency catheter ablation of atrial fibrillation (AF). However, the impact of LVAs on recurrence after an empiric pulmonary vein isolation (PVI) plus superior vena cava isolation (SVCI) strategy for non-Paroxysmal AF (PAF) patients remains unclear. Purpose We evaluated the impact of LVAs on the recurrence of atrial tachyarrhythmias (ATs)/AF in patients who underwent an empiric SVCI added to the PVI for non-PAF. Methods We enrolled 153 consecutive patients with non-PAF who underwent a PVI alone (PVI group; n=51) or empiric PVI plus SVCI (PVI+SVCI group; n=102). Left atrial voltage maps were constructed during sinus rhythm to identify the LVAs (<0.5 mV). No patients underwent a substrate modification of the LVAs. We divided the patients into two groups based on the LVAs (with or without an LVA >5% of the left atrial surface area) and investigated the ATs/AF free survival rate after the initial and multiple procedures. Results LVAs were identified in 65% and 73% of the PVI and PVI + SVCI groups, respectively (P=0.319). In the PVI group, the 18-month ATs/AF-free survival was 61% of the patients without LVAs and 27% of patients with LVAs after the initial session (P=0.018) (Figure 1-A). Seventy-two percent of the patients without LVAs and 46% of those with LVAs were free from ATs/AF after multiple sessions (P=0.083) (Figure 1-B). In the PVI+SVCI group, 50% of the patients with LVAs and 61% of those without LVAs had no recurrence after the initial session (P=0.374) (Figure 2-A). Moreover, there was no significant difference in the 18-month ATs/AF-free survival between the patients with and without LVAs after multiple sessions (73% vs. 79%; P=0.520) (Figure 2-B). Conclusion A PVI alone strategy for non-PAF patients with LVAs had limited efficacy for the outcomes, even with multiple procedures. However, an SVCI may have the potential to compensate for an impaired outcome in patients with LVAs. Funding Acknowledgement Type of funding source: None

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