Persistent atrial fibrillation: When the pulmonary veins are no longer the answer

Atrial fibrillation (AF) is a global disease with rapidly rising incidence and prevalence. It is associated with a higher risk of stroke, dementia, cognitive decline, sudden and cardiovascular death, heart failure and impairment in quality of life. The disease is a major burden on the healthcare system. Paroxysmal AF is typically managed with medications or endocardial catheter ablation to good effect. However, a large proportion of patients with AF have persistent or long-standing persistent AF, which are more complex forms of the condition and thus more difficult to treat. This is in part due to the progressive electro-anatomical changes that occur with AF persistence and the spread of arrhythmogenic triggers and substrates outside of the pulmonary veins. The posterior wall of the left atrium is a common site for these changes and has become a target of ablation strategies to treat these more resistant forms of AF. In this review, we discuss the role of the posterior left atrial wall in persistent and long-standing persistent AF, the limitations of current endocardial-focused treatment strategies, and future perspectives on hybrid epicardial–endocardial approaches to posterior wall isolation or ablation.

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Evaluation of a new approach for persistent atrial fibrillation: Ablation index-guided pulmonary veins isolation with contiguous lesions

Archives of Cardiovascular Diseases Supplements ◽

10.1016/j.acvdsp.2018.10.176 ◽

2019 ◽

Vol 11 (1) ◽

pp. 80

Author(s):

P. Taghji ◽

Sok-Sithikun Bun ◽

B. Enache ◽

Decebal Gabriel Latcu ◽

N. Saoudi

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Veins ◽

Persistent Atrial Fibrillation ◽

Atrial Fibrillation Ablation ◽

New Approach ◽

Ablation Index

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Simultaneous Catheter and Epicardial Ablations Enable a Comprehensive Atrial Fibrillation Procedure

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e31822ca15c ◽

2011 ◽

Vol 6 (4) ◽

pp. 243-247 ◽

Cited By ~ 11

Author(s):

Andy C. Kiser ◽

Mark D. Landers ◽

Ker Boyce ◽

Matjaž šinkovec ◽

Andrej Pernat ◽

...

Keyword(s):

Atrial Fibrillation ◽

Radiofrequency Ablation ◽

Sinus Rhythm ◽

Pulmonary Veins ◽

Persistent Atrial Fibrillation ◽

Chronic Atrial Fibrillation ◽

Lesion Pattern ◽

Atrial Size ◽

Cardiac Surgeon ◽

Successful Collaboration

Objective Transmural and contiguous ablations and a comprehensive lesion pattern are difficult to create from the surface of a beating heart but are critical to the successful treatment of persistent, isolated atrial fibrillation. A codisciplinary simultaneous epicardial (surgical) and endocardial (catheter) procedure (Convergent procedure) addresses these issues. Methods Patients with symptomatic atrial fibrillation who failed medical treatment were evaluated. Using only pericardioscopy, the surgeon performed near-complete epicardial isolation of the pulmonary veins and a “box” lesion on the posterior left atrium using unipolar radiofrequency ablation. Simultaneous endocardial catheter radiofrequency ablation completed pulmonary vein isolation, performed a mitral annular and cavotricuspid isthmus line of block, and debulked the coronary sinus. Twelve-month results for the Convergent procedure were compared with 12-month results for concomitant and pericardioscopic (stand-alone transdiaphragmatic/thoracoscopic) atrial fibrillation procedures using unipolar radiofrequency ablation. Results Sixty-five patients underwent the Convergent procedure (mean age, 62 y; mean body surface area, 2.17 m2; mean atrial fibrillation duration, 4.8 y; mean left atrial size, 5.2 cm). Ninety-two percent were in persistent or long-standing persistent atrial fibrillation. At 12 months, evaluation with 24-hour Holter monitors found 82% of patients in sinus rhythm, while only 47% of pericardioscopic and 77% of concomitant patients treated with unipolar radiofrequency ablation were in sinus rhythm. Conclusions Simultaneous epicardial and endocardial ablation improves outcomes for patients with persistent or longstanding persistent atrial fibrillation. This successful collaboration between cardiac surgeon and electrophysiologist is an important treatment option for patients with large left atriums and chronic atrial fibrillation.

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Electrical Isolation of Pulmonary Veins Using Laser Catheter in the Treatment of Paroxysmal and Persistent Atrial Fibrillation. One-year Results

Revista Española de Cardiología (English Edition) ◽

10.1016/j.rec.2015.08.022 ◽

2016 ◽

Vol 69 (5) ◽

pp. 488-493

Author(s):

Joaquín Osca ◽

Ana Andrés ◽

Oscar Cano ◽

Pau Alonso ◽

María José Sancho Tello ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Veins ◽

Persistent Atrial Fibrillation ◽

Electrical Isolation ◽

One Year

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Long-Standing Persistent Atrial Fibrillation Ablation: How Do You Perform? Left and Right Atrial Linear Ablation in Addition to Pulmonary Vein Isolation

Journal of Cardiac Arrhythmias ◽

10.24207/jca.v33i2.3407 ◽

2020 ◽

Vol 33 (2) ◽

pp. 106-114

Author(s):

Michele Brunelli ◽

Mark Adrian Sammut

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Low Voltage ◽

Superior Vena ◽

Pulmonary Veins ◽

Vena Cava ◽

Persistent Atrial Fibrillation ◽

Right Atrial ◽

Linear Ablation

Catheter ablation of long-standing persistent atrial fibrillation is not yet clearly defined with respect to endpoints, and different ablative strategies are offered to patients. Presented here is an approach aiming at biatrial debulking in the form of extensive linear ablation, specifically targeting areas of low-voltage complex fractionated electrograms, in addition to pulmonary vein isolation. Its main advantage is that it is not dependent on operator/system variability, since the strategy of isolating the pulmonary veins, superior vena cava and left atrial posterior wall together with achievement of bidirectional block during linear ablation provides objective endpoints that can consistently be reproduced.

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Abstract 16896: Electrogram Morphology Recurrence to Characterize Drivers of Persistent Atrial Fibrillation: Findings at Initial versus Redo Catheter Ablation

Circulation ◽

10.1161/circ.142.suppl_3.16896 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Ghaith Zaatari ◽

Jorge Bohorquez ◽

Raul Mitrani ◽

Jason Ng ◽

Justin Ng ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Cycle Length ◽

Cross Correlation ◽

Pulmonary Veins ◽

Persistent Atrial Fibrillation ◽

Success Rates ◽

Mapping Tool ◽

Group 2 ◽

Group 1

Background: Electrogram (EGM) morphology recurrence (EMR) mapping of persistent atrial fibrillation (PeAF) quantifies consistency of activation at each site and is expected to be high and rapid near drivers of PeAF. Objective: To compare EMR in the left (LA) and right atrium (RA) in patients undergoing first- vs second-time PeAF catheter ablation (CA). Methods: Multisite bipolar EGM mapping of the LA (265±153 sites) and RA (224±148 sites) prior to CA for PeAF was performed in 40 patients (29 males, age 63±9 yrs, CHA2DS2-VASc 2.4±1.5, LVEF 48±12%) undergoing first (Group 1, n=31) or second-time (Group 2, n=9) CA. After cross-correlation of each automatically detected EGM with every other EGM in the recording, the most recurrent EGM morphology was identified and its frequency (Rec%) and cycle length of recurrence (CL R ) were computed (figure). The minimum CL R sites were identified. Results: In group 1, shortest CL R was in the LA in 26 patients (84%) and RA in 5 patients (16%). In the LA, there were 1 (n=23), 2 (n=2), or 3 (n=1) areas of shortest CL R , most commonly in the pulmonary veins (PV; n=19). In the RA, there was only 1 area of shortest CL R . Minimum CL R was 174.1±25.4 ms (LA-179.6±37.4 vs RA-207.9±34.5, p=0.0004), with Rec% 95±10%. In group 2, shortest CL R was in the LA in 5 patients and RA in 5 patients (56%)– one had both LA and RA. In the LA/RA, there were 1 (n=3/4) or 2 (n=2/1) areas of shortest CL R . The most common LA site was non-PV (6/7, 85.7%). The minimum CL R was 182.1±26.2ms (LA-190.8±36.2 vs RA-196.0±30.5, p=0.6), with Rec% 96±5%. Conclusion: In 61% of patients undergoing initial CA for PeAF, EMR identified LA drivers in the PVs which may explain why PV isolation has been reported to have 50-60% success rates in PeAF. In patients undergoing a 2 nd ablation for PeAF, EMR identified predominantly nonPV drivers with even distribution of shortest CL R between RA and LA and diminished CL R gradient between the LA and RA. EMR may be a useful mapping tool to characterize potential drivers of PeAF.

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Common ostium of the left pulmonary veins – to freeze or not to freeze – that was the question?

In a good rythm ◽

10.5604/01.3001.0010.7497 ◽

2017 ◽

Vol 4 (45) ◽

pp. 33-34

Author(s):

Michał Orczykowski

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Second Generation ◽

Pulmonary Veins ◽

Persistent Atrial Fibrillation ◽

Clinical Results ◽

Common Pulmonary Vein

Second-generation cryoballoon (CB2) - based pulmonary vein isolation (PVI) has demonstrated encouraging clinical results in the treatment of paroxysmal (PAF) and persistent atrial fibrillation (PersAF). Nevertheless, the acute efficacy, safety, and long-term clinical results of CB2-based PVI in patients with a left common pulmonary vein (LCPV) are still a matter of debate. Commented paper by Heeger ChH, et al. analyzes this issue with some practical conclusions.

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