Atrial Fibrillation Ablation: State of the Art
Section snippets
Current Atrial Fibrillation Ablation Strategies: Comparative Data
Among several catheter-based strategies for AF treatment, 2 have emerged as dominant strategies in current clinical practice: 1 is aimed at ostial segmental disconnection of all PVs from the adjacent atrial tissue, and the other is aimed at anatomic circumferential ablation outside the PV ostia with additional lines as first described by our group.1 Is either of the 2 ablation strategies superior to the other, since the 2 proposed strategies are based on different rationales, require different
Atrial Fibrillation Mechanisms
To assess whether 1 strategy is superior to the other, it is crucial to understand the mechanisms that underlie human AF since the 2 proposed strategies are based on different rationales. The mechanisms of AF are complex and not yet well defined (Figure 1).8, 10, 14, 15, 16 Improvements in catheter ablation techniques essentially depend on better understanding of the mechanisms of this arrhythmia. Chronic AF is a highly heterogeneous and complex disease, and there are different mechanisms in
Anatomic Considerations
PV anatomic variability may have potential implications in the choice of the ablation approach. In patients with such PV anatomic variations, the circumferential approach is more favorable. One such variation is the presence of a common ostium of the left PVs, occurring in ≤32% of patients undergoing PV isolation. Such common ostia typically are too large to allow a stable position of the circumferential mapping catheter. Another anatomic variation is the presence of a right middle-lobe PV,
Patient population and selection
Over the last 5 years, >6,000 patients with either paroxysmal or chronic AF, many of whom had associated structural heart disease, were referred to our department for circumferential PV ablation. In our series the presence of heart failure, coronary artery disease, and mechanical prosthetic valves did not affect the outcome.
Mapping and ablation procedure
Three catheters are usually used: (1) a standard bipolar or quadripolar catheter in the right ventricular apex to provide backup pacing, (2) a quadripolar catheter in the
Safety and Efficacy
Complications of circumferential LA ablation are reported in Table 1. Postablation LA flutter is relatively common but usually does not require a repeat procedure because it generally resolves spontaneously within 5 months after the index procedure. Atrioesophageal fistula is rare, but its occurrence is dramatic and devastating.5 Lower RF energy application is recommended when ablating on the LA posterior wall; at present, the line is made on the posterior wall near the roof of the left atrium,
Anatomic, Electrical, and Functional Remodeling After Pulmonary Vein Ablation
Restoration of SR after ablation (usually by 5-month follow-up) results in “reverse” electrical and mechanical atrial remodeling and improved atrial function. Enlarged atria may become smaller, and this is associated with both electrical and mechanical changes. Among patients with mitral regurgitation who undergo ablation, anatomic remodeling is more pronounced and, interestingly, is associated with reduced mitral regurgitation and improved left ventricular function compared with patients in
Remote magnetic catheter navigation system for mapping and ablation of AF—a new era in interventional electrophysiology
A novel and promising approach to transcatheter AF ablation is the robotic magnetic navigation system for accurate mapping and ablation. The initial experience with this system in our laboratory has shown that the remote control of a soft magnetic catheter in patients with either paroxysmal or chronic AF is safe and feasible. This navigation system is integrated with a newly developed electroanatomic CARTO RMT (Biosense Webster, Inc.) mapping system. A special magnetic 4-mm tip mapping and
Conclusion
The circumferential PV approach to ablation can be safely performed in most patients with either paroxysmal or chronic AF, with high success rates that are maintained over the long term. With practice and new technology development, the procedure can be accomplished more quickly and can be safely performed even in less experienced centers, thus improving patient tolerance and exposing the patient to less risk.
References (17)
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Efficacy of a simple left atrial procedure for chronic atrial fibrillation in mitral valve operations
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Circumferential radiofrequency ablation of pulmonary vein ostiaa new anatomic approach for curing atrial fibrillation
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Atrial electroanatomic remodeling after circumferential radiofrequency PV ablation. Efficacy of an anatomic approach in a large cohort of patients with AF
Circulation
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PV denervation enhances long term benefit after circumferential ablation for paroxysmal AF
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Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of AF
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Catheter ablation for paroxysmal AFsegmental PV ostial ablation vs. left atrial ablation
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Cited by (60)
Catheter ablation for atrial fibrillation—Single center experience
2012, Cor et VasaCitation Excerpt :Catheter ablation (CA) has become standard therapy of atrial fibrillation (AF), especially for paroxysmal AF. Despite a high number of re-ablation procedures (30–50%), success is reported in 80–95% in patients with paroxysmal AF and 50–85% in patients with longstanding persistent AF; further, the complication rate is low (4–6%) [1–3] Precise single center follow-up (FU) data (especially long-term FU data) are published infrequently. The group consisted of 303 consecutive patients (172 males, 131 females, mean age 57 years) studied from April 2004 to August 2012.
Atrial fibrillation ablation
2012, Revista Espanola de CardiologiaRole of the CHADS<inf>2</inf> Score in the Evaluation of Thromboembolic Risk in Patients With Atrial Fibrillation Undergoing Transesophageal Echocardiography Before Pulmonary Vein Isolation
2009, Journal of the American College of CardiologyCitation Excerpt :The patient is maintained on a heparin infusion rate of 15 to 20 U/kg/h (14,15) and the infusion rate is adjusted to keep the activated clotting time in the range of 350 to 450 s. The PVI procedure was performed according to a standard measure as previously described elsewhere (3,4,6,17,18). There is no consensus in the management of LA/LAA sludge.