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Bi-directional electrical pulmonary vein isolation as an endpoint for ablation of paroxysmal atrial fibrillation

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Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Objective

Various approaches to pulmonary vein (PV) isolation have shown variable efficacy in patients with paroxysmal atrial fibrillation (AF). The purpose of this study is to report the efficacy and safety of routine isolation of all PVs using an endpoint of bi-directional electrical block.

Materials and methods

This study included 85 consecutive patients who underwent PV isolation for symptomatic paroxysmal AF. Complete isolation of all PVs was confirmed by demonstration of bi-directional block: (a) loss of all PV potentials, and (b) failure to capture the left atrium by pacing 10–14 bipolar pairs of electrodes on a circumferential catheter placed at the entrance of the PV at 10 mA with 2 ms pulse width. Induction of AF by burst pacing was attempted after PV isolation.

Results

Freedom from symptomatic or asymptomatic AF (detected by event recorder or Holter monitor) was present in 85% and 76% of patients at 6 and 12 months. Additional mitral isthmus or posterior left atrial lines were performed in seven patients with inducible atrial arrhythmias after PV isolation. Atrial tachycardia occurred in three of these patients during long-term follow-up and in two of the 78 patients without additional ablation.

Conclusion

The use of bi-directional block circumferentially across all PV ostia as an electrophysiological endpoint may improve results of PV isolation for paroxysmal AF. Avoidance of routine additional left atrial ablation lines may decrease the risk of atrial tachycardia and esophageal fistula.

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References

  1. Essebag, V., Wylie, J. V., & Josephson, M. E. (2006). Effectiveness of catheter ablation of atrial fibrillation. European Heart Journal, 27, 130–131.

    Article  PubMed  Google Scholar 

  2. Chen, S. A., Hsieh, M. H., Tai, C. T., Tsai, C. F., Prakash, V. S., Yu, W. C., et al. (1999). Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: Electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation, 100, 1879–1886.

    PubMed  CAS  Google Scholar 

  3. Haïssaguerre, M., Jaïs, P., Shah, D. C., Takahashi, A., Hocini, M., Quiniou, G., et al. (1998). Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. New England Journal of Medicine, 339, 659–666.

    Article  PubMed  Google Scholar 

  4. Haïssaguerre, M., Jaïs, P., Shah, D. C., Garrigue, S., Takahashi, A., Lavergne, T., et al. (2000). Electrophysiological end point for catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci. Circulation, 101, 1409–1417.

    PubMed  Google Scholar 

  5. Marchlinski, F. E., Callans, D., Dixit, S., Gerstenfeld, E. P., Rho, R., Ren, J. F., et al. (2003). Efficacy and safety of targeted focal ablation versus PV isolation assisted by magnetic electroanatomic mapping. Journal of Cardiovascular Electrophysiology, 14, 358–365.

    Article  PubMed  Google Scholar 

  6. Gerstenfeld, E. P., Callans, D. J., Dixit, S., Zado, E., & Marchlinski, F. E. (2003). Incidence and location of focal atrial fibrillation triggers in patients undergoing repeat pulmonary vein isolation: Implications for ablation strategies. Journal of Cardiovascular Electrophysiology, 14, 685–690.

    Article  PubMed  Google Scholar 

  7. Oral, H., Knight, B. P., Tada, H., Ozaydin, M., Chugh, A., Hassan, S., et al. (2002). Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation, 105, 1077–1081.

    Article  PubMed  Google Scholar 

  8. Hocini, M., Sanders, P., Jaïs, P., Hsu, L. F., Takahashi, Y., Rotter, M., et al. (2004). Techniques for curative treatment of atrial fibrillation. Journal of Cardiovascular Electrophysiology, 15, 1467–1471.

    Article  PubMed  Google Scholar 

  9. Pappone, C., Rosanio, S., Oreto, G., Tocchi, M., Gugliotta, F., Vicedomini, G., et al. (2000). Circumferential radiofrequency ablation of pulmonary vein ostia: A new anatomic approach for curing atrial fibrillation. Circulation, 102, 2619–2628.

    PubMed  CAS  Google Scholar 

  10. Pappone, C., & Santinelli, V. (2004). The who, what, why, and how-to guide for circumferential pulmonary vein ablation. Journal of Cardiovascular Electrophysiology, 15, 1226–1230.

    Article  PubMed  Google Scholar 

  11. Oral, H., Scharf, C., Chugh, A., Hall, B., Cheung, P., Good, E., et al. (2003). Catheter ablation for paroxysmal atrial fibrillation: Segmental pulmonary vein ostial ablation versus left atrial ablation. Circulation, 108, 2355–2360.

    Article  PubMed  Google Scholar 

  12. Pappone, C., Manguso, F., Vicedomini, G., Gugliotta, F., Santinelli, O., Ferro, A., et al. (2004). Prevention of iatrogenic atrial tachycardia after ablation of atrial fibrillation: A prospective randomized study comparing circumferential pulmonary vein ablation with a modified approach. Circulation, 110, 3036–3042.

    Article  PubMed  Google Scholar 

  13. Gerstenfeld, E. P., Dixit, S., Callans, D., Rho, R., Rajawat, Y., Zado, E., et al. (2002). Utility of exit block for identifying electrical isolation of the pulmonary veins. Journal of Cardiovascular Electrophysiology, 13, 971–979.

    Article  PubMed  Google Scholar 

  14. Takahashi, A., Iesaka, Y., Takahashi, Y., Takahashi, R., Kobayashi, K., Takagi, K., et al. (2002). Electrical connections between pulmonary veins: Implication for ostial ablation of pulmonary veins in patients with paroxysmal atrial fibrillation. Circulation, 105, 2998–3003.

    Article  PubMed  Google Scholar 

  15. McNamara, R. L., Brass, L. M., Drozda, J. P., Jr., Go, A. S., Halperin, J. L., Kerr, C. R., et al. (2004). ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association task force on clinical data standards (Writing committee to develop data standards on atrial fibrillation). Circulation, 109, 3223–3243.

    Article  PubMed  Google Scholar 

  16. Essebag, V., Baldessin, F., Reynolds, M. R., McClennen, S., Shah, J., Kwaku, K. F., et al. (2005). Non-inducibility post-pulmonary vein isolation achieving exit block predicts freedom from atrial fibrillation. European Heart Journal, 26, 2550–2555.

    Article  Google Scholar 

  17. Lee, S. H., Tai, C. T., Hsieh, M. H., Tsai, C. F., Lin, Y. K., Tsao, H. M., et al. (2004). Predictors of early and late recurrence of atrial fibrillation after catheter ablation of paroxysmal atrial fibrillation. Journal of Interventional Cardiac Electrophysiology, 10, 221–226.

    Article  PubMed  Google Scholar 

  18. Ouyang, F., Bansch, D., Ernst, S., Schaumann, A., Hachiya, H., Chen, M., et al. (2004). Complete isolation of left atrium surrounding the pulmonary veins: New insights from the double-Lasso technique in paroxysmal atrial fibrillation. Circulation, 110, 2090–2096.

    Article  PubMed  Google Scholar 

  19. Takahashi, Y., Iesaka, Y., Takahashi, A., Goya, M., Kobayashi, K., Fujiwara, H., et al. (2003). Reentrant tachycardia in pulmonary veins of patients with paroxysmal atrial fibrillation. Journal of Cardiovascular Electrophysiology, 14, 927–932.

    Article  PubMed  Google Scholar 

  20. Callans, D. J., Gerstenfeld, E. P., Dixit, S., Zado, E., Vanderhoff, M., Ren, J. F., et al. (2004). Efficacy of repeat pulmonary vein isolation procedures in patients with recurrent atrial fibrillation. Journal of Cardiovascular Electrophysiology, 15, 1050–1055.

    Article  PubMed  Google Scholar 

  21. Ouyang, F., Antz, M., Ernst, S., Hachiya, H., Mavrakis, H., Deger, F. T., et al. (2005). Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins: Lessons from double Lasso technique. Circulation, 111, 127–135.

    Article  PubMed  Google Scholar 

  22. Nanthakumar, K., Plumb, V. J., Epstein, A. E., Veenhuyzen, G. D., Link, D., & Kay, G. N. (2004). Resumption of electrical conduction in previously isolated pulmonary veins: Rationale for a different strategy? Circulation, 109, 1226–1229.

    Article  PubMed  Google Scholar 

  23. Lemola, K., Hall, B., Cheung, P., Good, E., Han, J., Tamirisa, K., et al. (2004). Mechanisms of recurrent atrial fibrillation after pulmonary vein isolation by segmental ostial ablation. Heart Rhythm, 1, 197–202.

    Article  PubMed  Google Scholar 

  24. Mesas, C. E., Pappone, C., Lang, C. C., Gugliotta, F., Tomita, T., Vicedomini, G., et al. (2004). Left atrial tachycardia after circumferential pulmonary vein ablation for atrial fibrillation: Electroanatomic characterization and treatment. Journal of the American College of Cardiology, 44, 1071–1079.

    Article  PubMed  Google Scholar 

  25. Gerstenfeld, E. P., Callans, D. J., Dixit, S., Russo, A. M., Nayak, H., Lin, D., et al. (2004). Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation. Circulation, 110, 1351–1357.

    Article  PubMed  Google Scholar 

  26. Oral, H., Chugh, A., Lemola, K., Cheung, P., Hall, B., Good, E., et al. (2004). Noninducibility of atrial fibrillation as an end point of left atrial circumferential ablation for paroxysmal atrial fibrillation: A randomized study. Circulation, 110, 2797–2801.

    Article  PubMed  Google Scholar 

  27. Pappone, C., Oral, H., Santinelli, V., Vicedomini, G., Lang, C. C., Manguso, F., et al. (2004). Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation, 109, 2724–2726.

    Article  PubMed  Google Scholar 

  28. Scanavacca, M. I., D’Avila, A., Parga, J., & Sosa, E. (2004). Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation. Journal of Cardiovascular Electrophysiology, 15, 960–962.

    Article  PubMed  Google Scholar 

  29. Karch, M. R., Zrenner, B., Deisenhofer, I., Schreieck, J., Ndrepepa, G., Dong, J., et al. (2005). Freedom from atrial tachyarrhythmias after catheter ablation of atrial fibrillation: A randomized comparison between 2 current ablation strategies. Circulation, 111, 2875–2880.

    Article  PubMed  Google Scholar 

  30. Senatore, G., Stabile, G., Bertaglia, E., Donnici, G., De Simone, A., Zoppo, F., et al. (2005). Role of transtelephonic electrocardiographic monitoring in detecting short-term arrhythmia recurrences after radiofrequency ablation in patients with atrial fibrillation. Journal of the American College of Cardiology, 45, 873–876.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Harvard-Thorndike Electrophysiology Institute Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Vidal Essebag, John V. Wylie Jr., Matthew R. Reynolds, Ferdinando Baldessin, Seth McClennen, Alexei Shvilkin, Joseph Germano, Allison Richardson, Peter J. Zimetbaum & Mark E. Josephson

  2. Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Baker 4, Boston, MA, 02215, USA

    Mark E. Josephson

Authors
  1. Vidal Essebag
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  2. John V. Wylie Jr.
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  3. Matthew R. Reynolds
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  4. Ferdinando Baldessin
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  5. Seth McClennen
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  6. Alexei Shvilkin
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  7. Joseph Germano
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  8. Allison Richardson
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  9. Peter J. Zimetbaum
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  10. Mark E. Josephson
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Corresponding author

Correspondence to Mark E. Josephson.

Additional information

Dr. Essebag is the recipient of a Clinician Scientist Award from the Canadian Institutes of Health Research (CIHR). Dr. Reynolds is the recipient of grant #1K23HL077171-01 from the National Heart, Lung, and Blood Institute (NHLBI).

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Essebag, V., Wylie, J.V., Reynolds, M.R. et al. Bi-directional electrical pulmonary vein isolation as an endpoint for ablation of paroxysmal atrial fibrillation. J Interv Card Electrophysiol 17, 111–117 (2006). https://doi.org/10.1007/s10840-006-9057-x

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  • DOI: https://doi.org/10.1007/s10840-006-9057-x

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