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Lessons learned in attempting catheter-based interatrial electrical disconnection for nonpharmacologic rate control of atrial fibrillation or flutter

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Abstract

Purpose

Ablation of atrioventricular (AV) conduction and pacemaker implantation is the therapy of last resort for symptomatic atrial tachyarrythmias when rhythm and rate control fail, but is far from ideal. To evaluate whether interatrial electrical disconnection as a result of catheter ablation is feasible and of potential clinical utility as a means of non-pharmacological heart rate control.

Methods

Eleven patients with medically refractory atrial fibrillation or left atrial flutter and symptomatic rapid ventricular response were included. The ablation strategy consisted primarily of right atrial ablation of the interatrial electrical connections, which were located by electroanatomical activation maps performed during coronary sinus stimulation. Successive activation maps were performed as each connection was blocked. If the procedure was considered unsuccessful AV nodal ablation was performed.

Results

The coronary sinus ostium was earliest in 10/11 and could be ablated in 5/10 patients. Interatrial conduction block was only achieved in one patient (9.1%). An unexpected AV nodal modulation with an increase in the Wenckebach cycle length (> 50 ms) occurred in 8/11 patients. These patients remained without pacemaker implantation and only 1/8 required AV nodal ablation during the 1-year follow-up. Quality of life questionnaires indicated significant improvement in patients with AV nodal modulation.

Conclusion

Interatrial electrical disconnection by right atrial catheter ablation is a not feasible with present day technology. The extensive right atrial septal ablation performed resulted in significant AV nodal modulation in most patients, which persisted and resulted in improvement in quality of life.

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Authors and Affiliations

  1. Arrhythmia Unit, Cardiology Service, University General Hospital of Alicante, Alicante Institute of Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain

    José Luis Ibáñez, Alicia Ibáñez, Raquel Ajo, Santiago Heras, Thomas Brouzet, Jessica Sánchez, María Ajo, Enrique Garcia, Juan Gabriel Martínez & Francisco Sogorb

  2. Electrophysiology Laboratory and Arrhythmia Unit, Hospital Monteprincipe, Grupo HM Hospitales, University CEU-San Pablo, Madrid, Spain

    Teresa Barrio, Mercedes Ortiz, Eduardo Castellanos & Jesús Almendral

Authors
  1. José Luis Ibáñez
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  2. Alicia Ibáñez
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  3. Teresa Barrio
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  4. Mercedes Ortiz
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  5. Raquel Ajo
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  6. Eduardo Castellanos
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  7. Santiago Heras
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  8. Thomas Brouzet
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  9. Jessica Sánchez
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  10. María Ajo
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  11. Enrique Garcia
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  12. Juan Gabriel Martínez
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  13. Francisco Sogorb
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  14. Jesús Almendral
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Corresponding author

Correspondence to José Luis Ibáñez.

Ethics declarations

The study was approved by the Ethics Committee of both institutions. Each patient gave written informed consent for both interatrial disconnection and AV node ablation with permanent pacemaker implantation.

Conflict of interest

The authors declare that they have no conflict of interest.

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Ibáñez, J.L., Ibáñez, A., Barrio, T. et al. Lessons learned in attempting catheter-based interatrial electrical disconnection for nonpharmacologic rate control of atrial fibrillation or flutter. J Interv Card Electrophysiol 57, 333–343 (2020). https://doi.org/10.1007/s10840-018-0448-6

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  • DOI: https://doi.org/10.1007/s10840-018-0448-6

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