Abstract
Both pulmonary veins (PVs) and the posterior left atrium (LA) are developed from the sinus venosus, where there are many pacemaker cells with spontaneous rhythmic activity. Non-PV foci originated mainly from the PV ostium or the posterior LA, and the posterior LA and the LA roof serve as a substrate for maintenance of AF in the patients with AF. It has been proposed that the surgical procedures for isolating the posterior LA and PVs could cure AF in 93% of patients with lone AF. These findings support that isolation of not only PVs but also the whole posterior LA can result in a much better cure rate in the patients with paroxysmal and persistent AF. Therefore, we developed a new approach for complete isolation of the posterior LA including all PVs, namely Box isolation. In the posterior LA, there are many arrhythmogenic substrates for AF, including the ganglionated plexi, reentries, triggers, and low-voltage areas. Box isolation can contain these abnormal substrates in the posterior LA and reduce the critical mass for maintenance of AF. Additional posterior LA isolation to PV isolation facilitates AF termination and non-inducibility. Previous studies reported that box isolation is an effective and safe treatment for paroxysmal or persistent AF. A meta-analysis showed that box isolation reduced AF recurrence with comparable recurrence rates of atrial tachycardia/flutter, complications, and procedure time compared with PV isolation alone.
References
Yamane T, Date T, Kanzaki Y, et al. Segmental pulmonary vein antrum isolation using the “large-size” lasso catheter in patients with atrial fibrillation. Circ J. 2007;71:753–60.
Ouyang F, Bansch D, Ernst S, et al. Complete isolation of left atrium surrounding the pulmonary veins: new insights from the double-Lasso technique in paroxysmal atrial fibrillation. Circulation. 2004;110:2090–6.
Verma A, Marrouche NF, Natale A. Pulmonary vein antrum isolation: intracardiac echocardiography-guided technique. J Cardiovasc Electrophysiol. 2004;15:1335–40.
Kamino K. Optical approaches to ontogeny of electrical activity and related functional organization during early heart development. Physiol Rev. 1991;71:53–91.
Mandapati R, Skanes A, Chen J, et al. Stable macroreentrant source as a mechanism of atrial fibrillation in the isolated sheep heart. Circulation. 2000;101:194–9.
Lim WS, Tai CT, Hsieh MH, et al. Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation. 2003;107:3176–83.
Marcids V, Schilling RJ, Ho SY, et al. Characterization of left atrial activation in the intact human heart. Circulation. 2003;107:733–9.
Hocini M, Jais P, Sanders P, et al. Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation: a prospective randomized study. Circulation. 2005;112:3688–96.
Todd DM, Skanes AC, Guiraudon G, et al. Role of the posterior left atrium and pulmonary veins in human lone atrial fibrillation: electrophysiological and pathological data from patients undergoing atrial fibrillation surgery. Circulation. 2003;108:3108–14.
Kumagai K, Muraoka S, Mitsutake C, et al. A new approach for complete isolation of the posterior left atrium including pulmonary veins for atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18:1047–52.
Verma A, Jiang CY, Betts TR, et al. STAR AF II Investigators. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015;372:1812–22.
Chang HY, Lo LW, Lin YJ, et al. Long-term outcome of catheter ablation in patients with atrial fibrillation originating from nonpulmonary vein ectopy. J Cardiovasc Electrophysiol. 2013;24:250–8.
Hayashi K, An Y, Nagashima M, Hiroshima K, et al. Importance of nonpulmonary vein foci in catheter ablation for paroxysmal atrial fibrillation. Heart Rhythm. 2015;12(9):1918–24.
Kumagai K. Catheter ablation of atrial fibrillation. State of the art. Circ J. 2011;75(10):2305–11.
Yamaguchi Y, Kumagai K, Nakashima H, et al. Long-term effects of box isolation on sympathovagal balance in atrial fibrillation. Circ J. 2010;74:1096–103.
Lim TW, Koay CH, See VA, et al. Single-ring posterior left atrial (box) isolation results in a different mode of recurrence compared with wide antral pulmonary vein isolation on long-term follow-up: longer atrial fibrillation-free survival time but similar survival time free of any atrial arrhythmia. Circ Arrhythm Electrophysiol. 2012;5(5):968–77.
Nalliah C, Lim TW, Bhaskaran A, et al. Posterior left atrial isolation for atrial fibrillation in left ventricular diastolic impairment is associated with better arrhythmia free survival. Int J Cardiol. 2015;184:674–9.
O'Neill L, Hensey M, Nolan W, et al. Clinical outcome when left atrial posterior wall box isolation is included as a catheter ablation strategy in patients with persistent atrial fibrillation. J Interv Card Electrophysiol. 2015;44(1):63–70.
Cutler MJ, Johnson J, Abozguia K, et al. Impact of voltage mapping to guide whether to perform ablation of the posterior wall in patients with persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2016;27(1):13–21.
Roberts JD, Gerstenfeld EP. Concomitant isolation of the pulmonary veins and posterior wall using a box lesion set in a patient with persistent atrial fibrillation and variant pulmonary venous anatomy. Cardiovasc Electrophysiol Clin. 2016;8(1):145–9.
He X, Zhou Y, Chen Y, et al. Left atrial posterior wall isolation reduces the recurrence of atrial fibrillation: a meta-analysis. J Interv Card Electrophysiol. 2016;46:267–74.
Kim JS, Shin SY, Na JO, et al. Does isolation of the left atrial posterior wall improve clinical outcomes after radiofrequency catheter ablation for persistent atrial fibrillation?: A prospective randomized clinical trial. Int J Cardiol. 2015;181:277–83.
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Kumagai, K. (2018). Catheter Ablation of Posterior LA Isolation: Box Isolation. In: Hirao, K. (eds) Catheter Ablation. Springer, Singapore. https://doi.org/10.1007/978-981-10-4463-2_17
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DOI: https://doi.org/10.1007/978-981-10-4463-2_17
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