The linear ablation of atrial fibrillation in the right atrium: can the isthmus ablation improve its efficacy? (original) (raw)
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Long-Term Follow-Up of Right Atrial Ablation in Patients with Atrial Fibrillation
Journal of Cardiovascular Electrophysiology, 2004
Introduction: The aim of this study was to evaluate the efficacy and the impact on quality of life of a new ablative approach to the right atrium in patients with atrial fibrillation (AF).Methods and Results: Seventy-four symptomatic patients with paroxysmal (n = 49) or permanent (n = 25) refractory AF underwent radiofrequency ablation. A nonfluoroscopic electroanatomic mapping system was used to perform the following lesions: (1) an isthmus line between the tricuspid annulus and the inferior vena cava; (2) a posterior intercaval line from the superior vena cava and the inferior vena cava; (3) a septal line from the superior vena cava to the fossa ovalis, proceeding to the coronary sinus ostium where a circumferential line around the ostium was performed, and then on to the inferior vena cava; and (4) a transversal lesion connecting the posterior intercaval and the septal lesions. In addition, electrical disconnection of the superior vena cava was performed. There were no complications. Postablation remapping showed the absence of discrete electrical activity inside and just around the ablation lines. Electrical disconnection of the superior vena cava was obtained in all patients. After 21 ± 6 months, 49 patients (66%) had stable sinus rhythm with continuation of the previous antiarrhythmic drug therapy, 13 patients (18%) were considered improved, and 12 (16%) received no benefit (unsuccessful procedure). After ablation, quality of life was significantly improved, reaching the levels of the general Italian population. Ejection fraction and the extent of the low-voltage area were found by multivariate analysis to be independent predictors of AF recurrence.Conclusion: The results of the present study suggest that this ablative approach in combination with antiarrhythmic drugs is safe and effective in treating AF, leading to a marked increase in quality of life in patients with refractory AF. (J Cardiovasc Electrophysiol, Vol. 15, pp. 37-43, January 2004)
Circulation, 2005
Background-Catheter ablation of the right atrial (RA) substrate has had variable efficacy in curing paroxysmal atrial fibrillation (PAF), suggesting that RA substrate ablation can play an important role in the treatment of atrial fibrillation (AF) in some patients. The aim of this study was to investigate the electrophysiological characteristics and ablation strategy and its results in a specific group of patients with paroxysmal RA-AF. Methods and Results-The study population consisted of 13 patients (8 men; age, 64Ϯ15 years) with drug-refractory (2Ϯ1 drugs), frequent episodes of PAF. Provocation maneuvers did not reveal any ectopic beat-initiating AF. However, rapid atrial pacing easily induced AF. Activation mapping during sinus rhythm, atrial pacing, and AF was visualized by using a noncontact mapping system. Noncontact mapping revealed RA reentry (6 patients with single-loop circuits and 7 with double-loop circuits) with conduction through channels between lines of block, crista terminalis gaps, and the cavotricuspid isthmus, which could be identified during sinus rhythm and atrial pacing, resulting in fibrillatory conduction in other parts of the RA. The consistency of wavefront activation was confirmed by frequency analysis from equally distributed mapping sites in the RA. Short lines of ablation lesions were aimed at the conduction channels between the lines of block, crista terminalis gaps, and the cavotricuspid isthmus, resulting in bidirectional block. AF was eliminated in 11 (85%) of 13 patients, and those 11 patients with acute success were free of AF without any antiarrhythmic drugs during the long-term follow-up period (16Ϯ6 months).
Editorial Atrial Fibrillation Ablation - Are we ready
Atrial fibrillation (AF) is the most common arrhythmia in day to day practice. It contributes to morbidity in the form of heart failure and stroke and increased overall and cardiovascular mortality 1 . Moreover, no treatment of AF to date has resulted in a lower overall death rate. Anti arrhythmic therapy for AF may also contribute to increased mortality in this subgroup 2 . Even though AFFIRM investigators showed no apparent benefit from rhythm control, these results cannot be generalized to younger patients, more symptomatic patients and those with rheumatic valvular disease. Catheter ablation for the same seems to be an attractive approach.
Circulation, 2004
Background-An anatomic approach of left atrial radiofrequency circumferential ablation (LACA) to encircle the pulmonary veins is often effective in eliminating paroxysmal atrial fibrillation (AF). However, no electrophysiological end points other than voltage abatement and/or conduction slowing or block across ablation lines have been used. It has been unclear whether noninducibility of AF is a clinically useful end point. Methods and Results-In 100 patients with paroxysmal AF (mean age, 55Ϯ10 years), LACA to encircle the left-and right-sided pulmonary veins was performed during AF, with additional ablation lines in the posterior left atrium and mitral isthmus, with an 8-mm-tip catheter. After completion of this lesion set, sinus rhythm was present, and AF lasting Ͼ60 seconds was not inducible in 40 patients (40%; group 1). The 60 patients in whom AF was still present or who still had inducible AF were randomly assigned to no further ablation (group 2; 30 patients) or to additional ablation lines along the left atrial septum, roof, and/or anterior wall where there were fractionated electrograms (group 3; 30 patients).
Atrial fibrillation ablation - are we ready?
Indian pacing and electrophysiology journal, 2007
Atrial fibrillation (AF) is the most common arrhythmia in day to day practice. It contributes to morbidity in the form of heart failure and stroke and increased overall and cardiovascular mortality 1. Moreover, no treatment of AF to date has resulted in a lower overall death rate. Anti arrhythmic therapy for AF may also contribute to increased mortality in this subgroup 2. Even though AFFIRM investigators showed no apparent benefit from rhythm control, these results cannot be generalized to younger patients, more symptomatic patients and those with rheumatic valvular disease. Catheter ablation for the same seems to be an attractive approach. Catheter ablation for AF is an evolving field. In the late 1990s, a group in Bordeaux demonstrated that the muscle sleeves that surround the pulmonary veins can be very arrhythmogenic and very often supply the triggers that set off atrial fibrillation. This resulted in opening up of new therapeutic avenue that is isolation of the pulmonary veins. Various techniques were described for the same like linear, focal ablation, PV isolation and circumferential antral ablation. Early linear ablation was an empirical version of a "catheter maze," initially limited to the right atrium. With the identification of PV foci, attention was soon directed at these specific targets. Initial ablations have been without 3 D mapping with use of Lasso or similar catheters. With continuous evolution of 3 D mapping techniques, circumferential antral ablation remains the most common technique used at this time. Variations of it like Wide Area Circumferential Ablation (WACA) or Left Atrial Catheter Ablation (LACA) and Pulmonary Vein Antrum Ablation/Isolation (PVAI) have resulted in better overall outcomes. Till date, however, there has been no standardization of the technique. Even though there is a trend towards better initial success, 6 month cure rates with new ablative techniques are still inferior to surgical results. Fisher et al 3 in reviewed all publications through 2005 if data included information on technique and 6 month follow up. More than 23000 subjects met the criteria. Cure rate with PVAI was 67 % at 6 months. 25% patients required repeat procedures. They observed trend towards inclusion of patients with permanent and persistent AF with improvement in the various mapping and ablative techniques. Although there is trend towards reduced fluoroscopy times, still it remains high, i.e. 201 min for PVAI. Complication rates remain high like stroke, repeat procedures, PV stenosis and catastrophic atrio-esophageal fistulae represent real limitation of AF ablative procedures. An atrio-esophageal fistula is a relatively recently recognized complication. Radiofrequency line on the posterior wall of LA can result in thermal injury to the esophagus, as the LA posterior wall is relatively thin measuring about 1.7-2 mms, whereas radiofrequency ablation can cause 4-5 mm Indian Pacing and Electrophysiology
Atrial fibrillation ablation guided with electroanatomical mapping system: A one year follow up
Medical Journal of Indonesia, 2010
Tujuan AF merupakan aritmia yang paling banyak ditemukan dalam praktek klinis dan berkaitan dengan peningkatan risiko stroke jangka panjang, gagal jantung dan segala sebab kematian. Ablasi kateter pada AF merupakan modalitas yang relatif baru untuk konversi AF ke irama sinus. Studi ini bertujuan untuk mengetahui efektifitas ablasi kateter pada tipe AF campuran. Metode 30 pasien (umur 52 ± 8 tahun) yang terdiri dari 19 paroksismal and 11 AF kronik dilakukan ablasi kateter radiofrekuensi dipandu oleh sistem pemetaan elektroanatomikal CARTO™. Digunakan pendekatan ablasi bertahap dengan isolasi vena pulmonalis (IVP) sebagai intinya. Tambahan ablasi berupa garis atap, garis mitral isthmus, complex fractionated atrial electrogram (CFAE), garis septal dan sinus koronarius dilakukan secara bertahap bila diperlukan. Pengamatan terhadap rekurensi AF dilakukan selama 1 tahun. Hasil IVP sirkumferensial berhasil dilakukan pada semua pasien kecuali 1 orang. Rata-rata masa pengamatan 11,5 bulan. Lebih dari 80% pasien masih dalam irama sinus pada akhir masa pengamatan dengan 62% di antaranya bebas dari obat anti-aritmia. Tidak terjadi komplikasi mayor pada serial pasien dalam studi ini. Kesimpulan Ablasi radiofrekuensi kateter yang dipandu oleh sistem pemetaan electroanatomikal efektif dan aman pada tipe AF campuran.