Left Atrial Fibrosis after Single Shot Guided Pulmonary Vein Isolation

Cryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment modality for patients with atrial fibrillation (AF) with encouraging acute and long-term outcome data. However, the size of collaterally created lesion sets adjacent to the pulmonary veins (PVs) remains unclear, especially when CB ablation is performed with individualized time-to-isolation (TTI) protocols. This study seeks to investigate the extension of lesions at the posterior wall and the roof of the left atrium (LA). Thirty patients with paroxysmal or persistent AF underwent ablation with a fourth-generation CB. The individual freeze-cycle duration was set at TTI + 120 s. A total of 120 PVs were identified, and all were successfully isolated. A three-dimensional electroanatomical high-density (HD) mapping of the LA was performed in every patient before and after PVI. The surface areas of the posterior wall and LA roof were measured and compared with lesion extension after PVI. After CB ablation, 65.6 ± 16.9% of the posterior wall and 75.4 ± 18.4% of the LA roof remained unablated. In addition, non-antral lesion formation was observed in every patient in at least one PV. After CB ablation, anterior antral parts of the superior PVs showed the greatest unablated areas compared with the other antral areas. HD re-mapping after CB-based PVI demonstrated that major regions of the posterior wall and roof remained electrically normal and unaffected. Unablated antral areas were localized predominantly in the anterior segments of the superior PVs and may be partly responsible for AF recurrence.

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Reconnection Rate and Long-Term Outcome with Adenosine Provocation During Cryoballoon Ablation for Pulmonary Vein Isolation

Journal of Atrial Fibrillation ◽

10.4022/jafib.1510 ◽

2017 ◽

Vol 9 (5) ◽

Cited By ~ 1

Author(s):

Rachel M Kaplan ◽

Sanjay Dandamudi ◽

Martha Bohn ◽

Nishant Verma ◽

Todd T Tomson ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Cryoballoon Ablation ◽

Reconnection Rate ◽

Term Outcome ◽

Long Term Outcome

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Long‐term outcome of percutaneous intervention for pulmonary vein stenosis after pulmonary vein isolation procedure

Catheterization and Cardiovascular Interventions ◽

10.1002/ccd.28628 ◽

2019 ◽

Vol 95 (3) ◽

pp. 389-397 ◽

Cited By ~ 1

Author(s):

Patcharapong Suntharos ◽

Sarah E. Worley ◽

Wei Liu ◽

Marion Siperstein ◽

Lourdes R. Prieto

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Percutaneous Intervention ◽

Isolation Procedure ◽

Pulmonary Vein Stenosis ◽

Term Outcome ◽

Long Term Outcome ◽

Vein Stenosis

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P1415Wide antral circumferential pulmonary vein isolation ablation using a novel balloon cryoablation catheter

EP Europace ◽

10.1093/europace/euaa162.203 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A P Martin ◽

M Fowler ◽

N Lever

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Paroxysmal Atrial Fibrillation ◽

Left Atrial ◽

Pulmonary Veins ◽

Posterior Wall ◽

The Novel ◽

Median Treatment

Abstract Background Pulmonary vein isolation using cryotherapy is an established treatment for the management of patients with paroxysmal atrial fibrillation. Ablation using the commercially available balloon cryocatheter has been shown to create wide antral pulmonary vein isolation. A novel balloon cryocatheter (BCC) has been designed to maintain uniform pressure and size during ablation, potentially improving contact with the antral anatomy. The extent of ablation created using the novel BCC has not previously been established. Purpose To determine the anatomical extent of pulmonary vein isolation using electroanatomical mapping when performing catheter ablation for paroxysmal atrial fibrillation using the novel BCC. Methods Nine consecutive patients underwent pre-procedure computed tomography angiography of the left atrium to quantify the chamber dimensions. An electroanatomical map was created using the cryoablation system mapping catheter and a high definition mapping system. A bipolar voltage map was obtained following ablation to determine the extent of pulmonary vein isolation ablation. A volumetric technique was used to quantify the extent of vein and posterior wall electrical isolation in addition to traditional techniques for proving entrance and exit block. Results All patients had paroxysmal atrial fibrillation, mean age 56 years, 7 (78%) male. Electrical isolation was achieved for 100% of the pulmonary veins; mean total procedure time was 109 min (+/- 26 SD), and fluoroscopy time 14.9 min (+/- 2.4 SD). The median treatment applications per vein was one (range one - four), and median treatment duration 180 sec (range 180 -240). Left atrial volume 32 mL/m2 (+/- 7 SD), and mean left atrial posterior wall area 22 cm2 (+/- 4 SD). Data was available for quantitative assessment of the extent of ablation for eight patients. No lesions (0 of 32) were ostial in nature. The antral surface area of ablation was not statistically different between the left and right sided pulmonary veins (p 0.63), which were 5.9 (1.6 SD) and 5.4 (2.1 SD) cm2 respectively. In total 50% of the posterior left atrial wall was ablated. Conclusion Pulmonary vein isolation using a novel BCC provides a wide and antral lesion set. There is significant debulking of the posterior wall of the left atrium. Abstract Figure.

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LONG-TERM OUTCOME OF PULMONARY VEIN ISOLATION WITH AND WITHOUT FOCAL IMPULSE AND ROTOR MODULATION (FIRM) MAPPING: RESULTS FROM A META-ANALYSIS

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(17)33783-x ◽

2017 ◽

Vol 69 (11) ◽

pp. 394 ◽

Cited By ~ 2

Author(s):

Sanghamitra Mohanty ◽

Prasant Mohanty ◽

Carola Gianni ◽

Chintan Trivedi ◽

Luigi Di Biase ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Meta Analysis ◽

Term Outcome ◽

Long Term Outcome

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Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: Treatment Strategy, Characteristics of Consecutive Atrial Tachycardia and Long‐Term Outcome

Journal of the American Heart Association ◽

10.1161/jaha.120.017451 ◽

2021 ◽

Vol 10 (3) ◽

Author(s):

Leon Dinshaw ◽

Paula Münkler ◽

Benjamin Schäffer ◽

Niklas Klatt ◽

Christiane Jungen ◽

...

Keyword(s):

Atrial Fibrillation ◽

Drug Therapy ◽

Hypertrophic Cardiomyopathy ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Term Outcome ◽

Long Term Outcome ◽

Antiarrhythmic Drug Therapy ◽

Af Ablation

Background Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and is associated with a deterioration of clinical status. Ablation of symptomatic AF is an established therapy, but in HCM, the characteristics of recurrent atrial arrhythmias and the long‐term outcome are uncertain. Methods and Results Sixty‐five patients with HCM (aged 64.5±9.9 years, 42 [64.6%] men) underwent AF ablation. The ablation strategy included pulmonary vein isolation in all patients and ablation of complex fractionated atrial electrograms or subsequent atrial tachycardias (AT) if appropriate. Paroxysmal, persistent AF, and a primary AT was present in 13 (20.0%), 51 (78.5%), and 1 (1.5%) patients, respectively. Twenty‐five (38.4%) patients developed AT with a total number of 54 ATs. Stable AT was observed in 15 (23.1%) and unstable AT in 10 (15.3%) patients. The mechanism was characterized as a macroreentry in 37 (68.5%), as a localized reentry in 12 (22.2%), a focal mechanism in 1 (1.9%), and not classified in 4 (7.4%) ATs. After 1.9±1.2 ablation procedures and a follow‐up of 48.1±32.5 months, freedom of AF/AT recurrences was demonstrated in 60.0% of patients. No recurrences occurred in 84.6% and 52.9% of patients with paroxysmal and persistent AF, respectively ( P <0.01). Antiarrhythmic drug therapy was maintained in 24 (36.9%) patients. Conclusions AF ablation in patients with HCM is effective for long‐term rhythm control, and especially patients with paroxysmal AF undergoing pulmonary vein isolation have a good clinical outcome. ATs after AF ablation are frequently observed in HCM. Freedom of atrial arrhythmia is achieved by persistent AF ablation in a reasonable number of patients even though the use of antiarrhythmic drug therapy remains high.

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P4764Relationship of the duration of pulmonary vein isolation-refractory non-paroxysmal atrial fibrillation to the middle- to long-term outcome of the ExTRa Mapping-guided ablation

European Heart Journal ◽

10.1093/eurheartj/ehz745.1140 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

Y Okuyama ◽

T Ashihara ◽

T Ozawa ◽

Y Fujii ◽

K Kato ◽

...

Keyword(s):

Atrial Fibrillation ◽

Real Time ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

High Density ◽

Term Outcome ◽

Long Term Outcome ◽

Mapping System ◽

Phase Mapping

Abstract Introduction It is reported that for patients with non-paroxysmal (persistent or long-standing persistent) atrial fibrillation (Non-PAF), extended ablation to atrial walls in addition to pulmonary vein isolation (PVI) did not improve the long-term outcome. On the other hand, modulation of Non-PAF drivers (or perpetuators) has been proposed as one of the alternative effective ablation strategies for Non-PAF. Purpose To clarify whether the rotor ablation under online real-time high-density phase mapping system is effective for PVI-refractory Non-PAF ablation. Methods Under such circumstances, our academic group had recently developed the online real-time high-density phase mapping system (ExTRa Mapping™) by industrial alliance. The phase map moving images were based on 41 intra-atrial bipolar signals recorded by a 20-pole spiral-shaped catheter (2.5 cm in diameter) and on in silicorapid prediction of spatio-temporal atrial excitations (artificial intelligence system). Then we applied the ExTRa Mapping to clinical practice in order to directly visualize rotors in patients with Non-PAF, and investigated the middle- to long-term outcome of the ExTRa Mapping-guided rotor ablation (ExTRa-ABL). Results Thirty-eight patients (63±8 y/o, 30 males) with Non-PAF demonstrating refractoriness to PVI were enrolled in this study. Ablation for cavo-tricuspid isthmus and/or superior vena cava isolation was additionally performed at physicians' discretion. After these procedures, the ExTRa-ABL was performed in order to modify Non-PAF substrates, causing rotor control. The modification of the rotors was evaluated by re-mapping with the use of the ExTRa Mapping at the end of each ablation session. Patients were followed at 1, 3, 6 months and every year after the procedure. All of them were followed for 21±8 months. During the follow-up period, Non-PAF was recurred in only 8 of 38 (21%). Furthermore, we found if PVI-refractory Non-PAF duration was shorter than 6 years, the non-recurrence rate remained ≥80% (see Figure), which was markedly better outcome comparing with previous reports with regard to Non-PAF ablation. Figure 1 Conclusion Comparing with conventional Non-PAF ablation strategies, our novel approach with the use of the online real-time high-density phase mapping system might improve medium- to long-term outcome of PVI-refractory Non-PAF treatment.

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Abstract 15553: The Long-term Outcome Beyond Pulmonary Vein Isolation of Ablation Guided by the Online and Real-time Atrial Fibrillation Imaging System: Extra Mapping Project

Circulation ◽

10.1161/circ.142.suppl_3.15553 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Kensuke Sakata ◽

Yusuke Okuyama ◽

Tomoya Ozawa ◽

Yusuke Fujii ◽

Koichi Kato ◽

...

Keyword(s):

Atrial Fibrillation ◽

Real Time ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Propensity Scores ◽

Imaging System ◽

Strategy Group ◽

Term Outcome ◽

Long Term Outcome ◽

Meta Analyses

Introduction: Although modulation of atrial fibrillation (AF) drivers and/or substrates has been proposed as one of the effective ablation strategies for non-paroxysmal AF (Non-PAF), previous meta-analyses showed that ablation, targeting complex fractionated atrial electrogram (CFAE) indirectly-reflecting Non-PAF drivers, had no additional benefit for post-pulmonary vein isolation (PVI) Non-PAF. As an alternative ablation strategy for Non-PAF, rotor ablation has been proposed as one of the potentiated ablation strategies for Non-PAF. However, the optimal ablation strategy is still unclear because reliable method detecting AF drivers remain unsettled in clinical practice. Hypothesis: Because rotors are known as key mechanisms for Non-PAF, we might open the possibility of Non-PAF control by the real-time visualization of wave dynamics during AF ablation. Methods: Consecutive 140 Non-PAF patients were enrolled in this study. The clinically-available online and real-time AF imaging system with high-spatiotemporal density (ExTRa Mapping TM ) developed by our group was applied in case Non-PAF was remained after PVI. Then, we detected and ablated non-passively-activated areas where rotational activations in the form of meandering rotors and/or multiple wavelets assumed to contain Non-PAF drivers were frequently observed (figure, top). The recurrence rate of Non-PAF or atrial tachycardia (AT) after the ablation was compared to that in patients underwent PVI-alone at our hospital. Results: The propensity scores selected each 34 people from ExTRa-strategy group and PVI-alone group (figure, middle). The 24-month freedom ratio from Non-PAF/AT in the matched-ExTRa-strategy group was higher than the matched-PVI-alone group, which was close to significance (p = 0.056) (figure, bottom). Conclusion: The ExTRa Mapping-guided ablation for PVI-refractory Non-PAF might be superior to PVI-alone.

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