Response of Atrial Fibrillation to Pulmonary Vein Antrum Isolation Is Directly Related to Resumption and Delay of Pulmonary Vein Conduction

Klinikum Coburg, Landkreis Coburg, Bavaria, Germany
Circulation (Impact Factor: 14.43). 09/2005; 112(5):627-35. DOI: 10.1161/CIRCULATIONAHA.104.533190
Source: PubMed


The role of pulmonary vein (PV) isolation in ablative treatment of atrial fibrillation (AF) has been debated in conflicting reports. We sought to compare PV conduction in patients who had no AF recurrence (group I), patients who could maintain sinus rhythm on antiarrhythmic medication (group II), and patients who had recurrent AF despite antiarrhythmic medication (group III) after PV antrum isolation (PVAI).
PV conduction was examined in consecutive patients undergoing second PVAI for AF recurrence. We also recruited some patients cured of AF to undergo a repeat, limited electrophysiological study at >3 months after PVAI. All patients underwent PVAI with an intracardiac echocardiography (ICE)-guided approach with complete isolation of all 4 PV antra (PVA). The number of PVs with recurrent conduction and the shortest atrial to PV (A-PV) conduction delay was measured with the use of consistent Lasso positions defined by ICE. Late AF recurrence was defined as AF >2 months after PVAI with the patient off medications. Patients in groups I (n=26), II (n=37), and III (n=44) did not differ at baseline (38% permanent AF; ejection fraction 53+/-6%). Recurrence of PV-left atrial (LA) conduction was seen in 1.7+/-0.8 and 2.2+/-0.8 PVAs for groups II and III but only in 0.2+/-0.4 for group I (P=0.02). In patients with recurrent PV-LA conduction, the A-PV delay increased from the first to second procedure by 69+/-47% for group III, 267+/-110% for group II, and 473+/-71% for group I (P<0.001). When pacing was at a faster rate, A-PV block developed in all 5 of the group I patients with recurrent PV-LA conduction.
The majority of patients with drug-free cure show no PV-LA conduction recurrence. Substantial A-PV delay is seen in patients able to maintain sinus rhythm on antiarrhythmic medication or cured of AF compared with patients who fail PVAI.

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Available from: Ennio Pisanò, Mar 11, 2015
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    • "Durable transmurality of the ablation lines is considered the gold standard for the current treatment of atrial fibrillation (AF). One of the key aspects of AF treatment consists in ablating the pulmonary vein (PV) ostia, generally one of the thickest areas of the left atrium, obtaining their electrical disconnection [1] [2] [3]. Many technological refinements were introduced in recent years to ameliorate the efficacy of ablative energy sources, in particular bipolar radiofrequency (RF) lesions proved to be reproducibly transmural and contiguous on the cardiac muscle [4] [5]. "
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    ABSTRACT: Clinical success of atrial fibrillation (AF) ablation depends on persistent block of electrical conduction across the ablation lines. The fate of ablations performed with temperature-controlled bipolar radiofrequency (RF) is unknown. The purpose of this study was to validate the electrophysiological (EP) efficacy of these lesions, recording pulmonary vein isolation (PVI) after open chest ablation, in the human being. Ten consecutive mitral patients (mean age: 53 ± 12 years) with concomitant AF were treated with the Cobra Revolution (Estech, San Ramon, CA, USA) bipolar RF device were enrolled for EP assessment. During surgery, pairs of additional temporary wires were positioned on the right PVs (RPV) and on the roof of the left atrium (RLA), before ablation. Pacing thresholds (PTs) were assessed before, after a single encircling ablation and at chest's closure. EP study was repeated before discharge and at 3 weeks. RLA wires served as control. Baseline PTs were 0.83 ± 0.81 mA (range 0.2-3 mA) from RPV and 1.13 ± 0.78 mA (range 0.3-3 mA) from RLA. PVI was reached in all patients acutely, and was maintained at 1 week. At 3 weeks, the PTs were 14.3 ± 4.3 mA from RPV (range 7-20 mA) and 3.1 ± 1.3 mA (range 1.5-7 mA) from RLA. All patients were discharged in sinus rhythm. Cobra Revolution temperature-controlled bipolar RF provides complete PVI after a single ablation up to 1 week. This notwithstanding, only 30% of patients were completely isolated (exit block validation) at 3 weeks. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
    Full-text · Article · Feb 2015 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery
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    • "AF recurrences post PVI are mainly due to PV re-conduction in ablated myocardium or sometimes to non-PV foci13-16. To test the hypothesis that P-wave duration could be a marker of a successful PVI, Date et al17 studied the contribution of PV cardiac muscles to the P-wave using standard vectorcardiography and electrocardiography recorded before and after the procedure. "
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    ABSTRACT: P-wave indices are appealing markers for predicting atrial fibrillation (AF) recurrences post ablation. This study evaluates the value of P wave indices to predict recurrences post pulmonary vein isolation (PVI) in patients with paroxysmal AF. We selected 198 patients (57 ± 8 years, 150 males) with symptomatic drug-refractory paroxysmal AF undergoing PVI in our hospital. A 12-lead electrocardiogram was used to measure P wave duration in lead II, P wave terminal force (PWTF) in lead V1, P wave axis and dispersion. During a follow-up of 9 ± 3 months, recurrences occurred in 60 (30.3%) patients. The patients that had AF recurrence had longer mean P wave duration (122.9 ± 10.3 vs 104.3 ± 14.2 ms, p < 0.001), larger P wave dispersion (40.7 ± 1.7 ms vs 36.6 ± 3.2 ms, p < 0.001). P wave duration > 125 ms has 60% sensitivity, 90% specificity, positive predictive value (PPV) of 72% and negative predictive value (NPV) of 83.7%, whereas P wave dispersion > 40 ms has 78% sensitivity, 67% specificity, PPV of 51% and NPV of 87.6% 48/66 (72.7%) patients with PWTF < -0.04 mm/second vs12/132(9%) with PWTF > -0.04 mm/second showed recurrence of AF (p < 0.001). P wave axis was not different between two groups. On multivariate analysis, P wave indices were not independent from left atrial size and age. P wave duration > 125 ms, P wave dispersion > 40 ms and PWTF in V1 < -0.04 mm/sec are good clinical predictors of AF recurrences post PVI in patients with paroxysmal atrial fibrillation; however they were not independent from left atrial size and age.
    Full-text · Article · Nov 2013 · Arquivos brasileiros de cardiologia
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    • "However, not all patients with gaps had AF recurrence. This is in keeping with several clinical studies that have identified the presence of reconnected veins in patients free from AF who volunteered for a restudy following AF ablation.26 "
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    ABSTRACT: BACKGROUND: For late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) assessment of atrial scar to guide management and targeting of ablation in AF, an objective, reproducible method of identifying atrial scar is required. Objective: We describe an automated method for operator-independent quantification of LGE that correlates with co-located endocardial voltage and clinical outcomes. METHODS: LGE CMR imaging was performed at 2 centres, before and 3 months after pulmonary vein isolation (PVI) for paroxysmal AF (PAF) (N=50). Left atrial (LA) surface scar map was constructed using automated software, expressing intensity as multiples of standard deviation (SD) above blood pool mean. 21 patients underwent endocardial voltage mapping at the time of PVI (11 were redo procedures). Scar maps and voltage maps were spatially registered to the same MRA segmentation. RESULTS: LGE levels of 3, 4 and 5 SD above blood pool intensity were associated with progressively lower bipolar voltages compared to the preceding enhancement level (0.85± 0.33mV, 0.50± 0.22mV and 0.38 ±0.28mV, p=0.002, p<0.001 and p=0.048 respectively).The proportion of atrial surface area classified as scar (i.e. >3 SD above blood pool mean) on pre-ablation scans was greater in patients with post-ablation AF recurrence than those without recurrence (6.6 ± 6.7% vs 3.5 ± 3.0%, p =0.032). LA volume >102ml was associated with a significantly greater proportion of LA scar (6.4± 5.9 vs 3.4± 2.2%, p=0.007). CONCLUSION: Left atrial scar quantified automatically by a simple objective method correlates with co-located endocardial voltage. Greater pre-ablation scar is associated with LA dilatation and AF recurrence.
    Full-text · Article · May 2013 · Heart rhythm: the official journal of the Heart Rhythm Society
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