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What Is the Appropriate Lesion Set for Ablation in Patients with Persistent Atrial Fibrillation?

  • Arrhythmia (D Spragg, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

Special attention must be paid to detect, diagnose, and optimize management of reversible or treatable causes of long-standing persistent atrial fibrillation (LSPAF) such as obesity, obstructive sleep apnea (OSA), hypertension, hypo or hyperthyroidism, inflammatory and infectious diseases, and stress. Though, we strongly believe that the role of the pulmonary veins (PVs) is more pronounced in paroxysmal atrial fibrillation (AF) than in persistent AF, performing an adequate pulmonary vein isolation is still key in LSPAF. Patients with LSPAF will frequently require a more aggressive mapping and ablative approach. We do not encourage the use of empiric lines or complex fractionated atrial electrograms. Ablation of sites associated with non-PV triggers such as the entire posterior wall, the roof, the anterior part of the left atrium septum, left atrial appendage (LAA), the CS and SVC has been shown to improve the freedom from AF at follow-up when combined with PVs isolation. During the isoproterenol challenge, non-PV triggers are detected in most patients with AF. Mapping non-PV triggers is guided by multiple catheters positioned along both the right and left atriums: a 10-pole circular mapping catheter in the left superior PV recording the far-field LAA activity, the ablation catheter in the right superior PV that records the far-field interatrial septum and a 20-pole catheter with electrodes spanning from the SVC to the CS. With this simple catheter setup, when focal ectopic atrial activity is observed (a single ectopic beat is enough) their activation sequence is compared to that of sinus rhythm, allowing to quickly identify their area of origin. For significant non-PV triggers (repetitive isolated beats, focal atrial tachycardias or beats triggering AF/atrial flutter, a more detailed activation mapping is performed in the area of origin. They are subsequently targeted with focal ablation, exception being the triggers originating from the SVC, LAA or CS, in which cases complete isolation of these structures is the ablation strategy of choice. We truly believe the LAA deserves special consideration when managing patients with persistent AF and LSPAF.

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Abbreviations

AF:

Atrial fibrillation

CA:

Catheter ablation

CFAE:

Complex fractionated atrial electrograms

CF:

Contact force

CS:

Coronary sinus

SVC:

Superior vena cava

FIRM:

Focal impulse rotor modulation

GP:

Ganglionated plexus

LA:

Left atrium

LAA:

Left atrial appendage

OSA:

Obstructive sleep apnea

PVI:

Pulmonary vein isolation

RA:

Right atrium

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Authors and Affiliations

  1. Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA

    Jorge Romero MD, Carola Gianni MD, Andrea Natale MD & Luigi Di Biase MD-PhD

  2. Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, TX, USA

    Carola Gianni MD, Andrea Natale MD & Luigi Di Biase MD-PhD

  3. Department of Biomedical Engineering, University of Texas, Austin, TX, USA

    Carola Gianni MD, Andrea Natale MD & Luigi Di Biase MD-PhD

  4. Department of Cardiology, University of Foggia, Foggia, Italy

    Luigi Di Biase MD-PhD

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  1. Jorge Romero MD
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  2. Carola Gianni MD
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  4. Luigi Di Biase MD-PhD
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Correspondence to Luigi Di Biase MD-PhD.

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Jorge Romero and Carola Gianni each declare no potential conflicts of interest. Andrea Natale received speaker honorariums from Boston Scientific, Biosense Webster, Medtronic, and St. Jude. Luigi Di Biase is a consultant for Biosense Webster, Boston Scientific, and St Jude Medical. Dr. Di Biase has received speaker honoraria/travel from Medtronic, Atricure, EPiEP, and Biotronik.

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Romero, J., Gianni, C., Natale, A. et al. What Is the Appropriate Lesion Set for Ablation in Patients with Persistent Atrial Fibrillation?. Curr Treat Options Cardio Med 19, 35 (2017). https://doi.org/10.1007/s11936-017-0534-6

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