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The modified ablation index: a novel determinant of acute pulmonary vein reconnections after pulmonary vein isolation

  • Yuji Wakamatsu
  • Koichi NagashimaEmail author
  • Ichiro Watanabe
  • Ryuta Watanabe
  • Masaru Arai
  • Naoto Otsuka
  • Seina Yagyu
  • Sayaka Kurokawa
  • Kimie Ohkubo
  • Toshiko Nakai
  • Yasuo Okumura
Article

Abstract

Background

Although pulmonary vein isolation (PVI) guided by the ablation index (AI) has been well-developed, acute PV reconnections (PVRs) still occur. This study aimed to compare the prognostic performance of the modified AI and its optimal cut-off value for the prediction of acute PVRs to ensure durable PVI.

Methods

Three-dimensional left atrium (LA) voltage maps created before an extensive encircling PVI in 64 patients with atrial fibrillation (AF) (45 men, 62 ± 10 years) were examined for an association between electrogram voltage amplitude recorded from the PV–LA junction and acute post-PVI PVRs (spontaneous PVRs and/or ATP-provoked dormant PV conduction).

Results

Acute PVRs were observed in 22 patients (34%) and 33 (3%) of the 1012 PV segments. Acute PVRs were significantly associated with segments with higher bipolar voltage zones (3.23 ± 1.17 vs. 1.97 ± 1.20 mV, P < 0.0001), lower mean AI values (449 [428–450] vs. 460 [437–486], P = 0.05), and radiofrequency lesion gaps ≥ 6 mm (48 vs. 32%, P = 0.04), but not with contact force, force–time integral, or power. We created the modified AI calculated as AI/LA bipolar voltage, and found it to be significantly lower in areas with acute PVRs than in those without (152 [109–185] vs. 256 [176–413] AU/mV, P < 0.0001). Univariate analysis showed the prognostic performance of the modified AI, with an area under the curve of 0.801 (0.775–0.825), to be the highest of all the significant parameters.

Conclusions

Low values of the novel modified AI on the PV-encircling ablation line were strongly associated with acute PVRs.

Keywords

Atrial fibrillation Pulmonary vein isolation Catheter ablation Ablation index High-voltage zone Force–time integral 

Abbreviations

AF

Atrial fibrillation

AI

Ablation index

ATP

Adenosine triphosphate

AUC

Area under the curve

CF

Contact force

EEPVI

Extensive encircling pulmonary vein isolation

FTI

Force–time integral

HVZ

High-voltage zone

LA

Left atrium

LIPV

Left inferior pulmonary vein

LSPV

Left superior pulmonary vein

PV

Pulmonary vein

PVI

Pulmonary vein isolation

PVR

Pulmonary vein reconnection

RF

Radiofrequency

RIPV

Right inferior pulmonary vein

ROC

Receiver-operating characteristic

RSPV

Right superior pulmonary vein

Notes

Acknowledgements

The study was supported by departmental resources only.

Compliance with ethical standards

Conflict of interest

The authors have no conflict of interest to declare.

References

  1. 1.
    Neuzil P, Reddy VY, Kautzner J, Petru J, Wichterle D, Shah D, et al. Electrical reconnection after pulmonary vein isolation is contingent on contact force during initial treatment: results from the EFFICAS I study. Circ Arrhythm Electrophysiol. 2013;6(2):327–33.  https://doi.org/10.1161/circep.113.000374.CrossRefPubMedGoogle Scholar
  2. 2.
    Reddy VY, Shah D, Kautzner J, Schmidt B, Saoudi N, Herrera C, et al. The relationship between contact force and clinical outcome during radiofrequency catheter ablation of atrial fibrillation in the TOCCATA study. Heart Rhythm. 2012;9(11):1789–95.  https://doi.org/10.1016/j.hrthm.2012.07.016.CrossRefPubMedGoogle Scholar
  3. 3.
    Phlips T, Taghji P, El Haddad M, Wolf M, Knecht S, Vandekerckhove Y, et al. Improving procedural and one-year outcome after contact force-guided pulmonary vein isolation: the role of interlesion distance, ablation index, and contact force variability in the ‘CLOSE’-protocol. EUROPACE. 2018.  https://doi.org/10.1093/europace/eux376.
  4. 4.
    Das M, Loveday JJ, Wynn GJ, Gomes S, Saeed Y, Bonnett LJ, et al. Ablation index, a novel marker of ablation lesion quality: prediction of pulmonary vein reconnection at repeat electrophysiology study and regional differences in target values. EUROPACE. 2017;19(5):775–83.  https://doi.org/10.1093/europace/euw105.CrossRefPubMedGoogle Scholar
  5. 5.
    Hussein A, Das M, Chaturvedi V, Asfour IK, Daryanani N, Morgan M, et al. Prospective use of ablation index targets improves clinical outcomes following ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2017;28(9):1037–47.  https://doi.org/10.1111/jce.13281.CrossRefPubMedGoogle Scholar
  6. 6.
    Taghji P, El Haddad M, Phlips T, Wolf M, Knecht S, Vandekerckhove Y, et al. Evaluation of a strategy aiming to enclose the pulmonary veins with contiguous and optimized radiofrequency lesions in paroxysmal atrial fibrillation: a pilot study. JACC Clin Electrophysiol. 2018;4(1):99–108.  https://doi.org/10.1016/j.jacep.2017.06.023.CrossRefPubMedGoogle Scholar
  7. 7.
    Baldinger SH, Kumar S, Barbhaiya CR, Nagashima K, Epstein LM, John R, et al. The timing and frequency of pulmonary veins unexcitability relative to completion of a wide area circumferential ablation line for pulmonary vein isolation. JACC Clin Electrophysiol. 2016;2(1):14–23.  https://doi.org/10.1016/j.jacep.2015.09.010.CrossRefPubMedGoogle Scholar
  8. 8.
    Schwartzman D, Ren JF, Devine WA, Callans DJ. Cardiac swelling associated with linear radiofrequency ablation in the atrium. J Interv Card Electrophysiol. 2001;5(2):159–66.CrossRefGoogle Scholar
  9. 9.
    Arujuna A, Karim R, Caulfield D, Knowles B, Rhode K, Schaeffter T, et al. Acute pulmonary vein isolation is achieved by a combination of reversible and irreversible atrial injury after catheter ablation: evidence from magnetic resonance imaging. Circ Arrhythm Electrophysiol. 2012;5(4):691–700.  https://doi.org/10.1161/circep.111.966523.CrossRefPubMedGoogle Scholar
  10. 10.
    Nagashima K, Watanabe I, Okumura Y, Iso K, Takahashi K, Watanabe R, et al. High-voltage zones within the pulmonary vein antra: major determinants of acute pulmonary vein reconnections after atrial fibrillation ablation. J Interv Card Electrophysiol. 2017;49(2):137–45.  https://doi.org/10.1007/s10840-017-0252-8.CrossRefPubMedGoogle Scholar
  11. 11.
    Okumura Y, Watanabe I, Iso K, Nagashima K, Sonoda K, Sasaki N, et al. Clinical utility of automated ablation lesion tagging based on catheter stability information (VisiTag module of the CARTO 3 system) with contact force-time integral during pulmonary vein isolation for atrial fibrillation. J Interv Card Electrophysiol. 2016;47:245–52.  https://doi.org/10.1007/s10840-016-0156-z.CrossRefPubMedGoogle Scholar
  12. 12.
    Kautzner J, Neuzil P, Lambert H, Peichl P, Petru J, Cihak R, et al. EFFICAS II: optimization of catheter contact force improves outcome of pulmonary vein isolation for paroxysmal atrial fibrillation. EUROPACE. 2015;17(8):1229–35.  https://doi.org/10.1093/europace/euv057.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Macle L, Khairy P, Weerasooriya R, Novak P, Verma A, Willems S, et al. Adenosine-guided pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation: an international, multicentre, randomised superiority trial. Lancet (London, England). 2015;386(9994):672–9.  https://doi.org/10.1016/s0140-6736(15)60026-5.CrossRefGoogle Scholar
  14. 14.
    Matsuo S, Yamane T, Date T, Inada K, Kanzaki Y, Tokuda M, et al. Reduction of AF recurrence after pulmonary vein isolation by eliminating ATP-induced transient venous re-conduction. J Cardiovasc Electrophysiol. 2007;18(7):704–8.  https://doi.org/10.1111/j.1540-8167.2007.00842.x.CrossRefPubMedGoogle Scholar
  15. 15.
    Verma A, Jiang CY, Betts TR, Chen J, Deisenhofer I, Mantovan R, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015;372(19):1812–22.  https://doi.org/10.1056/NEJMoa1408288.CrossRefPubMedGoogle Scholar
  16. 16.
    Iso K, Okumura Y, Watanabe I, Nagashima K, Sonoda K, Kogawa R, et al. Wall thickness of the pulmonary vein-left atrial junction rather than electrical information as the major determinant of dormant conduction after contact force-guided pulmonary vein isolation. J Interv Card Electrophysiol. 2016;46:325–33.  https://doi.org/10.1007/s10840-016-0147-0.CrossRefPubMedGoogle Scholar
  17. 17.
    Haissaguerre M, Shah DC, Jais P, Hocini M, Yamane T, Deisenhofer I, et al. Electrophysiological breakthroughs from the left atrium to the pulmonary veins. Circulation. 2000;102(20):2463–5.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Yuji Wakamatsu
    • 1
  • Koichi Nagashima
    • 1
    Email author return OK on get
  • Ichiro Watanabe
    • 1
  • Ryuta Watanabe
    • 1
  • Masaru Arai
    • 1
  • Naoto Otsuka
    • 1
  • Seina Yagyu
    • 1
  • Sayaka Kurokawa
    • 1
  • Kimie Ohkubo
    • 1
  • Toshiko Nakai
    • 1
  • Yasuo Okumura
    • 1
  1. 1.Division of Cardiology, Department of MedicineNihon University School of MedicineItabashi-kuJapan

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