Pulmonary vein isolation combined with superior vena cava isolation for atrial fibrillation ablation: a prospective randomized study
ABSTRACT Circumferential pulmonary vein isolation (CPVI) is an established strategy for atrial fibrillation (AF) ablation. Superior vena cava (SVC), by harbouring the majority of non-pulmonary vein (PV) foci, is the most common non-PV origin for AF. However, it is unknown whether CPVI combined with SVC isolation (SVCI) could improve clinical results and whether SVCI is technically safe and feasible.
A total of 106 cases (58 males, average age 66.0 +/- 8.8 years) with paroxysmal AF were included for ablation. They were allocated randomly to two groups: CPVI group (n = 54) and CPVI + SVCI group (n = 52). All cases underwent the procedure successfully. Pulmonary vein isolation was achieved in all cases. The procedural time and fluoroscopic time were comparable between the two groups. The mean ablation time for SVC was 7.8 +/- 2.7 min. Superior vena cava isolation was obtained in 50/52 cases. In the remaining two cases, SVCI was not achieved because of obviating diaphragmatic nerve injury. During a mean follow-up of 4 +/- 2 months, 12 (22.2%) cases in the CPVI group and 10 (19.2%) cases in the CPVI + SVCI group had atrial tachyarrhythmias (ATa) recurrence (P = 0.70). Nine of 12 cases in the CPVI group and 8/10 cases in the CPVI + SVCI group underwent reablation (P = 0.86), and PV reconnection occurred in 7/9 cases in the CPVI group and in 8/8 cases in the CPVI + SVCI group. All PV reconnection was reisolated by gaps ablation. There was no SVC reconnection in the CPVI + SVCI group. In two cases without PV reconnection from the CPVI group, SVC-originated short run of atrial tachycardia was identified and eliminated by the SVCI. At the end of 12 months of follow-up, 50 cases (92.6%) in the CPVI group and 49 (94.2%) in the CPVI + SVC group were free of ATa recurrence (P = 0.73).
In our series of paroxysmal AF patients, empirically adding SVCI to CPVI did not significantly reduce the AF recurrence after ablation. Superior vena cava isolation may be useful, however, in selected patients in whom the SVC is identified as a trigger for AF. However, because of the preliminary property of the study and its relatively small sample size, the impact of SVCI on clinical results should be evaluated in a large series of patients.
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ABSTRACT: As the most common sustained cardiac arrhythmia, atrial fibrillation (AF) is the primary cause of many hospital admissions (1), and is associated with significant secondary morbidity by increasing the risk of stroke (2), heart failure (3), and all-cause mortality (4). The incidence of AF is on the rise, and it is projected that by the year 2050 more than 10 million patients will be affected by AF in the U. S. alone (5). Antiarrhythmic medications have limited success in maintaining sinus rhythm, are associated with side effects, and seem to be ineffective at reducing mortality compared with a strategy of rate control and anticoagulation (6).Journal of the American College of Cardiology 11/2008; 52(15):1272-3. DOI:10.1016/j.jacc.2008.07.015 · 15.34 Impact Factor
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ABSTRACT: Catheter ablation is effective in treating patients with atrial fibrillation (AF). The aim of the study was to evaluate the safety, efficacy and outcome of catheter ablation for AF in octogenarians. 377 consecutive patients were divided into three groups based on age: ≥80 years (group 1; n=49), 70-79 years (group 2; n=151), 60-69 years (group 3; n=177). The efficacy and safety for those three groups were determined. The success rate after one procedure was similar in three groups (70% in group 1, 72% in group2 and 74% in group 3, P=NS) during a mean follow-up of 18 months. Major complication rates were comparable between the three groups. However, the octogenarians were less likely to undergo a repeated procedure than other groups (8% in group 1, 15% in group 2 and 18% in group 3, P<0.05), and were more likely to remain on antiarrhythmic drugs. Catheter ablation for AF attempted in octogenarians appears to be effective and with low risk. Ablation results are comparable with those noted in younger patients.International journal of cardiology 08/2009; 145(1):147-8. DOI:10.1016/j.ijcard.2009.06.055 · 6.18 Impact Factor
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ABSTRACT: Atrial fibrillation is the most common sustained arrhythmia. Medical treatment often fails to control symptoms. To compare the benefits and harms of radiofrequency catheter ablation and medical therapy in adults with atrial fibrillation. MEDLINE and the Cochrane Central Register of Controlled Trials (2000 to December 2008) were searched for English-language reports of studies in adults. 6 independent reviewers screened abstracts to identify longitudinal studies of adults with atrial fibrillation who underwent radiofrequency catheter ablation. Studies reported arrhythmia or other cardiovascular outcomes at least 6 months after ablation or any adverse events. Data were extracted by 1 of 4 reviewers and were verified by a cardiac electrophysiologist. Study quality and overall strength of evidence for each question were rated by 2 independent reviewers; disagreements were resolved by consensus. 108 studies met eligibility criteria. Moderate strength of evidence (3 trials; n = 30 to 198) showed that radiofrequency ablation after a failed drug course was more likely than continuation of drug therapy alone to lead to maintained sinus rhythm. Low strength of evidence (4 trials [n = 30 to 137] and 1 retrospective study [n = 1171]) suggested that radiofrequency ablation improved quality of life, promoted avoidance of anticoagulation, and decreased readmission rates compared with medical treatment. Major adverse events occurred in fewer than 5% of patients in most of 84 studies. Study follow-up was generally 12 months or less. Large heterogeneity of applied techniques and reporting of outcomes precluded many definitive conclusions. Reporting of adverse events was poor. Publication and selective reporting biases could not be ruled out. Studies with small samples and studies reported in a language other than English were excluded. Radiofrequency catheter ablation is effective for up to 12 months of rhythm control when used as a second-line therapy for atrial fibrillation in relatively young patients with near-intact cardiac function. Longer studies that use primary end points of stroke and mortality are needed.Annals of internal medicine 09/2009; 151(3):191-202. · 16.10 Impact Factor