Advertisement

Ablation of permanent AF

Adjunctive strategies to pulmonary veins isolation: Targeting AF NEST in sinus rhythm and CFAE in AF
  • Mauricio ArrudaEmail author
  • Andrea Natale
Article

Abstract

Atrial fibrillation (AF) is highly prevalent and accounts for significant morbidity, mortality, and health care costs. Catheter ablation has become a therapeutic option in the management of this challenging arrhythmia. To optimize procedure safety and long-term efficacy, innovative technologies and ablation strategies have been targeting either the triggers initiating AF or the substrate responsible for its maintenance. Pulmonary vein (PV) isolation, initially limited to the PVs, has been modified to encompass the left atrial myocardium surrounding the PV ostia, namely the LA-PV antra. Our current intracardiac echo-guided approach to PV antra isolation, including the adjunct of superior vena cava isolation, has likely accounted for higher success rates by electrically isolating further AF trigger sites, modifying the substrate for AF maintenance and possibly by modulating a dysfunctional autonomic cardiac nervous system. However, the long-term outcome following ablation of permanent AF can be further improved by incorporating adjunctive ablation strategies to PV isolation, such as targeting ablation at sites exhibiting complex atrial fractionated electrograms (CFAEs)during AF or at sites exhibiting the so-called AF nests during real-time spectral mapping in sinus rhythm.

Keywords

Catheter ablation Atrial fibrillation Atrial fibrillation ablation Permanent atrial fibrillation 

References

  1. 1.
    Marrouche, N. F., Dresing, T., Cole, C., Bash, D., Saad, E., Balaban, K., et al. (2002). Circular mapping and ablation of the pulmonary vein for treatment of atrial fibrillation: Impact of different catheter technologies. Journal of the American College of Cardiology, 40(3), 464–474, (Aug 7).PubMedCrossRefGoogle Scholar
  2. 2.
    Marrouche, N. F., Martin, D. O., Wazni, O., Gillinov, A. M., Klein, A., Bhargava, M., et al. (2003). Phased-array intracardiac echocardiography monitoring during pulmonary vein isolation in patients with atrial fibrillation: Impact on outcome and complications. Circulation, 107(21), 2710–2716, (Jun 3).PubMedCrossRefGoogle Scholar
  3. 3.
    Verma, A., Marrouche, N. F., & Natale, A. (2004). Pulmonary vein antrum isolation: Intracardiac echocardiography guided technique. Journal of Cardiovascular Electrophysiology, 15(11), 1335–1340.Google Scholar
  4. 4.
    Bhargava, M., Marrouche, N., Martin, D., Burghardt, D., Khaykin, Y., Joseph, G., et al. (2004). Chronic cure rate after pulmonary vein isolation in patients with nonparoxysmal atrial fibrillation: Impact of a second ablation. Journal of the American College of Cardiology, 43(5), 133A.CrossRefGoogle Scholar
  5. 5.
    Arruda, M., & Natale, A. (2006). The adjunctive role of nonpulmonary venous ablation in the cure of atrial fibrillation. Journal of Cardiovascular Electrophysiology, 17(3), 37.CrossRefGoogle Scholar
  6. 6.
    Arruda, M., Mlcochova, H., Prasad, S., Kilicaslan, F., Saliba, W., Patel, D., et al. (2007). Electrical isolation of the superior vena cava: An adjunctive strategy to pulmonary vein antrum isolation—Improving the outcome of AF ablation. Journal of Cardiovascular Electrophysiology 18, 1261–1266.Google Scholar
  7. 7.
    Konings, K. T., Smeets, J. L., Penn, O. C., Wellens, H. J., & Allessie, M. A. (1997). Configuration of unipolar atrial electrograms during electrically induced atrial fibrillation in humans. Circulation, 95(5), 1231–1241.PubMedGoogle Scholar
  8. 8.
    Jais, P., Haissaguerre, M., Shah, D. C., Chouairi, S., & Clementy, J. (1996). Regional disparities of endocardial atrial activation in paroxysmal atrial fibrillation. Pacing and Clinical Electrophysiology, 19(11 Pt 2), 1998–2003.PubMedCrossRefGoogle Scholar
  9. 9.
    Nademanee, K., McKenzie, J., Kosar, E., Schwab, M., Sunsaneewitayakul, B., Vasavakul, T., et al. (2004). A new approach for catheter ablation of atrial fibrillation: Mapping of the electrophysiologic substrate. Journal of the American College of Cardiology, 43(11), 2044–2053.PubMedCrossRefGoogle Scholar
  10. 10.
    Oral, H., Chugh, A., Good, E., Igic, P., Elmouchi, D., Tschopp, D. R., et al. (2005). Randomized comparison of encircling and nonencircling left atrial ablation for chronic atrial fibrillation. Heart Rhythm, 2(11), 1165–1172.PubMedCrossRefGoogle Scholar
  11. 11.
    Haissaguerre, M., Sanders, P., Hocini, M., Takahashi, Y., Rotter, M., Sacher, F., et al. (2005). Catheter ablation of long-lasting persistent atrial fibrillation: Critical structures for termination. Journal of Cardiovascular Electrophysiology, 16(11), 1125–1137.PubMedCrossRefGoogle Scholar
  12. 12.
    Nakagawa, H., Jackman, W., Scherlag, B., Yokoyama, K., Wu, R., Oza, S., et al. (2005). Relationship of complex fractionated atrial electrograms during atrial fibrillation to the location of cardiac automatic ganglionated plexi in patients with atrial fibrillation. Circulation, 112(17), II–746.Google Scholar
  13. 13.
    Pachon, M. J. C., Pachon, M. E. I., Pachon, M. J. C., Lobo, T. J., Pachon, M. Z., Vargas, R. N., et al. (2004). A new treatment for atrial fibrillation based on spectral analysis to guide the catheter RF-ablation. Europace, 6(6), 590–601.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Electrophysiology and Atrial Fibrillation Center, University Hospitals Heart & Vascular InstituteCase Western Reserve University School of MedicineClevelandUSA
  2. 2.Texas Cardiac Arrhythmias InstituteAustinUSA

Personalised recommendations