Efficacy of multi-electrode duty-cycled radiofrequency ablation for pulmonary vein disconnection in patients with paroxysmal and persistent atrial fibrillation.
ABSTRACT A novel multi-electrode pulmonary vein ablation catheter (PVAC) combining circular mapping and duty-cycled multi-electrode radiofrequency (RF) energy delivery has been developed to map and isolate the pulmonary veins (PVs). The aim of this study was to assess the efficacy of multi-electrode RF ablation using the PVAC device.
A total of 102 consecutive patients, age 57.9 +/- 9.6 years, with paroxysmal or persistent drug refractory atrial fibrillation (AF) were referred for ablation. All patients had documented AF episodes with an AF duration of 9.3 +/- 7.5 years (range 1.5-25). The mean total procedure time was 139.30 +/- 37.72 (median 135, range 115-172). The mean fluoroscopy time required for PVAC ablation was 17 +/- 12 min (median 16, range 12-33) and the total fluoroscopy time was 32.1 +/- 11.3 min (median 29, range 25-39). The mean multi-electrode RF ablation time required to achieve complete PV isolation was 31 +/- 6.7 min (range 16-51). In eight patients with persistent AF, additional ablations were performed to defragment septal and posterior part of the left atrium. In five patients additional RF ablations using conventional catheters were necessary. After multi-electrode duty-cycled RF ablation, 62 of 102 (60.8%) patients were in sustained sinus rhythm without anti-arrhythmic drugs. The mean follow-up duration was 12.2 +/- 3.9 months (range 6-15).
This novel multi-electrode ablation technique can be used for PV isolation and left atrium ablation with a relatively low medium-term success rate after the first ablation of approximately 61%. Larger studies with longer follow-up are required to evaluate the efficacy and whether multi-electrode RF ablation is associated with a different complication rate compared with standard PV isolation.
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ABSTRACT: Drug-refractory atrial fibrillation (AF) increasingly is being treated with catheter ablation. However, the long-term success rate, expressed as freedom from AF, is <50%. Therefore, vitamin K antagonists, with all their complications, remain necessary. Recently, left atrial appendage (LAA) occlusion devices were introduced as an alternative to vitamin K antagonists. Here, we investigated whether AF ablation and LAA occlusion could be a feasible and safe combination in patients with symptomatic drug-refractory AF and a CHADS(2) score ≥1 or a contraindication for vitamin K antagonists. Ablation was performed by using multielectrode catheters with phased radiofrequency energy. LAA was occluded with the Watchman device (Atritech, Inc, Plymouth, MN). Between February 2010 and February 2011, 30 patients were treated (21 male; age, 62.8±8.5 years). Median CHADS(2) score was 2.5 (25th to 75th percentiles: 2 to 3), median CHADS-VASc score was 3 (25th to 75th percentiles: 3 to 5), 77% had prior stroke, and 27% had a contraindication for vitamin K antagonists. Median HAS-BLED score was 2 (range, 1 to 5). Successful device implantation was achieved with a median number of 1.5 devices (median diameter 24 mm [25th to 75th percentiles: 24 to 24 mm]). Total procedure time was 97 minutes (25th to 75th percentiles: 75 to 115 minutes). At 60 days, all patients met the criteria for successful sealing. Follow-up visit at 12 months showed a 30% rate of documented recurrence of AF. A repeated pulmonary vein isolation was performed successfully in 4 patients, without interference of the LAA closure device. No thromboembolic events occurred during 1-year follow-up. LAA occlusion with the Watchman device and AF ablation can be combined successfully and safely in a single procedure. The Watchman does not interfere with a repeated ablation.Journal of the American Heart Association. 10/2012; 1(5):e002212.
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ABSTRACT: Anatomic variability of the pulmonary vein (PV) ostium may adversely affect isolation rates with the circular fixed-size pulmonary vein ablation catheter (PVAC). We wanted to assess the influence on PV isolation rates of anatomic characteristics of the ostium, increasing experience of four different operators, and additional use of a steerable sheath. In the first 190 patients (pts) undergoing PVAC ablation, minimum/maximum diameter, area and shape of the PV ostia, and the length of a common ostium were analysed from computed tomography 3D reconstructions of the left atrium and related to isolation rates. In addition, a comparison was drawn between pts at the beginning and after completion (isolation of all PVs in ≥ 85% of pts) of the learning curve, and the effect of a steerable sheath was assessed. Pulmonary vein isolation was achieved with the PVAC alone in 85% of pts and in 94% of veins after a median procedure and ablation time of 154 [interquartile ranges (IQR): 120, 200] and 51 (IQR: 38, 70) min. An increase in isolation rates was observed after the first 60 pts (73 vs. 90% of pts; P< 0.01; 88 vs. 96% of PVs; P< 0.001), coincident with routine use of a steerable sheath. Anatomic characteristics (larger minimum diameter and area) identified unsuccessful isolation only of the left inferior PV at the beginning of the learning curve. Pulmonary vein isolation rates using this catheter are high. Anatomic variability of PV ostia modestly affects PV isolation rates. Standard use of a steerable sheath plays a major role in increasing isolation rates and overcoming 'difficult' anatomies.Europace 03/2012; 14(3):331-40. · 2.77 Impact Factor
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ABSTRACT: PURPOSE: Pulmonary vein isolation (PVI) using phased radiofrequency (RF) energy has been shown to be effective in the treatment of paroxysmal atrial fibrillation (AF). We characterize pulmonary vein (PV) conduction at repeat ablation in patients with AF after an initial successful PVI using phased RF technology and analyze the effects of a primary 2:1 ablation mode. METHODS AND RESULTS: A primary 4:1 bipolar/unipolar mode in group A patients (n = 22) was compared with a primary 2:1 mode in group B (n = 22) acutely and during follow-up. Of all PVs, 81 % showed reconnection(s); 52 % of them had reconnected in all PVs. PVI was achieved in all patients without complications. Procedure and fluoroscopy times were shorter in group B (108 ± 15 vs. 126 ± 24 min and 17 ± 5 vs. 23 ± 7 min, respectively). This was attributed to a significant decrease of early PV reconnections within the first 30 min in 17 % of group B patients vs. 45 % of group A patients (p < 0.001). After 9.5 ± 4 months, recurrence of AF was detected in 5 of 22 patients (22.7 %) in group A vs. 3 of 22 patients (13.6 %) in group B (p = 0.722). CONCLUSIONS: Phased RF energy applied by a 2:1 bipolar/unipolar mode seems safe and effective in redo-PVI procedures, resulting in a mid-term freedom from AF in 86.4%. Significant shorter procedure and fluoroscopy times compared with a primary 4:1 ablation mode during repeat PVI are mainly attributed to a lower incidence of acutely reconnected PVs within the first 30 min.Journal of Interventional Cardiac Electrophysiology 10/2012; · 1.39 Impact Factor