Catheter Ablation of Long-Lasting Persistent Atrial Fibrillation

Clinical Outcome and Mechanisms of Subsequent Arrhythmias

Michel Hassaguerre, MD; Mélèze Hocini, MD; Prashanthan Sanders, MBBS, PhD; Frederic Sacher, MD; Martin Rotter, MD; Yoshihide Takahashi, MD; Thomas Rostock, MD; Li-Fern Hsu, MBBS; Pierre Bordachar, MD; Sylvain Reuter, MD; Raymond Roudaut, MD; Jacques Clémenty, MD; Pierre Jas, MD

Disclosures

J Cardiovasc Electrophysiol. 2005;16(11):1138-1147. 

In This Article

Abstract and Introduction

Abstract

Background: Catheter ablation of atrial fibrillation (AF) is challenging in patients with long-standing persistent AF. The clinical outcome and subsequent arrhythmia recurrence after using an ablation method targeting multiple left atrial sites with the aim of achieving acute AF termination has not been characterized.
Methods: Sixty patients (mean age: 53 ± 9 years) with persistent AF (mean duration: 17 ± 27 months) were prospectively followed after catheter ablation. Catheter ablation targeting the following sites was performed in a random sequence: (i) electrical isolation of all pulmonary veins (PV); (ii) disconnection of other thoracic veins; (iii) atrial ablation at sites possessing complex electrical activity, activation gradients, or short cycle lengths. Finally, linear ablation of the LA roof and mitral isthmus was performed if sinus rhythm was not restored following energy delivery to the above sites. At 1, 3, 6, and 12 months after ablation, patients underwent clinical review and 24-hour ambulatory ECG monitoring to identify asymptomatic arrhythmia. Repeat mapping and catheter ablation was performed in any patient experiencing recurrent atrial tachycardia (AT). Clinical success was defined as the absence of any sustained atrial arrhythmia.
Results: AF terminated during ablation in 52 patients (87%). The fluoroscopy and procedural durations were 84 ± 30 minutes and 264 ± 77 minutes, respectively. Three months after ablation, sustained ATs were documented in 24 patients (associated with AF in 2). Mapping in 23 patients showed a single AT in 7 while multiple ATs were observed in 16. Macroreentry was confirmed to be due to gaps in the ablation lines, while focal ATs originated from discrete sites or isthmuses near the left atrial appendage, coronary sinus, pulmonary veins, or fossa ovalis; these sites were similar to those at which the greatest impact was observed on the fibrillatory process during the initial ablation procedure. After repeat ablation, at 11 ± 6 months of follow-up, 57 patients (95%) were in sinus rhythm and 3 developed recurrent AF or AT. All patients in sinus rhythm demonstrated improved exercise capacity and all but 2 had evidence of atrial transport as assessed by Doppler echocardiography (mitral A wave velocity 34 ± 17 cm/sec) by 6 months.
Conclusion: Catheter ablation of long-lasting persistent AF associated with acute AF termination achieves medium to long-term restoration and maintenance of sinus rhythm in 95% of patients. Arrhythmia recurrence in the majority of patients is AT.

Introduction

Antiarrhythmic drugs have been the mainstay of maintaining sinus rhythm for many patients with persistent atrial fibrillation (AF). However, their limited efficacy and potential for significant adverse effects has led to renewed interest in rate control measures. This concept has been strengthened by the publication of the "Atrial Fibrillation Follow-Up Investigation of Rhythm Management" (AFFIRM),[1] the "Rate Control versus Electrical Cardioversion" (RACE),[2] and the "Pharmacological Intervention in Atrial Fibrillation" (PIAF) trials,[3] which suggested an equivalent outcome for pharmacological rhythm and rate-control strategies. However, emerging evidence suggests that these findings merely highlighted the fact that the benefits of sinus rhythm can be negated by the deleterious effects of antiarrhythmic drugs.[4,5] Indeed, a further analysis of the AFFIRM results demonstrated that sinus rhythm was associated with a 47% lower risk of death, while the use of antiarrhythmic drugs significantly increased mortality risk by 49%.[4] Thus, the restoration and maintenance of sinus rhythm is of potential benefit if it can be achieved without the use of antiarrhythmic drugs.

Several nonpharmacological strategies have been proposed for the curative treatment of AF in addition to simple pulmonary vein (PV) isolation.[6,7,8,9,10,11,12,13,14,15,16,17,18,19] These have included extensive or limited linear lesions[6,7,8,9,10,11] and ablation of fractionated potentials,[12] areas of short cycle length activity,[13] those demonstrating a frequency gradient,[14] or a source indicated by centrifugal activity.[19] These approaches have been used separately rather than in combination and have been variably effective in the ablation of persistent AF. In this prospective clinical study, we evaluate the clinical outcome of an approach utilizing the above techniques in all left atrial or venous regions with completeness of linear lesions in patients with persistent AF.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....