Abstract
Background
Pulmonary vein isolation (PVI) is not always achieved after initial encircling of the pulmonary veins (PVs). Additional touch-up lesions are frequently required to close residual gaps, which may occur both in the initial ablation line and on the intervenous carina.
Purpose
We aimed to identify determinants and prognostic implications of residual gaps during index radiofrequency PVI.
Methods
Two hundred fourteen AF (atrial fibrillation) patients (57% paroxysmal, 61% male, mean age 62±9 years) undergoing contact force-guided PVI were studied. Residual gaps after initial encircling of the PVs were targeted for additional ablation and were classified as either gap ablation in the initial WACA (wide-area circumferential ablation) circle or carina ablation, depending on the site of earliest activation. After a waiting period of at least 30 minutes, persistence of PVI was tested through administration of 9–18 mg intravenous adenosine. Pre-procedural cardiac computed tomography imaging was used to assess left atrial and PV anatomy. Carina width was defined as the distance between ipsilateral superior and inferior PV ostia. Ablation procedures were analyzed to define the perimeter of the WACA circle.
Results
One hundred thirty-three patients (62%) required additional ablation lesions beyond the initial WACA circles to achieve complete PVI. Gap ablation was required in the left WACA circle in 34 patients (16%) and in the right WACA circle in 49 patients (23%). Left and right carina ablation were required in 50 (23%) and 83 (39%) patients, respectively. Multivariate analyses identified carina width and perimeter of the WACA circle as independent predictors of requirement for ipsilateral carina ablation, whereas paroxysmal AF and the perimeter of the WACA circle were associated with requirement of gap ablation in the initial WACA circle. Recurrence of atrial tachyarrhythmias was documented in 73 patients (34%) at 12 months follow-up. Kaplan–Meier survival analyses demonstrated a significantly higher rate of recurrence in patients with one or more residual gaps in the ablation line (43% vs. 30%, p=0.019, figure A), whereas no significant difference between patients with and without requirement of carina ablation was found (38% and 29%, respectively; p=0.111, figure B).
Kaplan-Meier survival analyses
Conclusion
Residual gaps in the initial WACA circle were associated with increased AF recurrence rate after PVI, whereas residual gaps on the intervenous carina had no statistically significant impact on AF recurrence. Consequently, gaps occurring in the ablation line and gaps on the intervenous carina may represent different mechanisms and may have different prognostic implications.
Difference Between Dormant Conduction Sites Revealed by Adenosine Triphosphate Provocation and Unipolar Pace-Capture Sites Along the Ablation Line After Pulmonary Vein Isolation