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Challenging Achievement of Bidirectional Block After Linear Ablation Affects the Rhythm Outcome in Patients With Persistent Atrial Fibrillation

View Article: PubMed Central - PubMed

ABSTRACT

Background: It is not clear whether bidirectional block (BDB) of linear ablations reduces atrial fibrillation (AF) recurrence after radiofrequency catheter ablation. We hypothesized that BDB of linear ablation has prognostic significance after radiofrequency catheter ablation for persistent AF.

Methods and results: Among 1793 consecutive patients in the Yonsei AF ablation cohort, this observational cohort study included 398 patients with persistent AF (75.6% male; age, 59.8±10.3 years) who underwent catheter ablation with a consistent ablation protocol of the Dallas lesion set: circumferential pulmonary vein isolation; cavotricuspid isthmus ablation (CTI); roof line (RL); posterior‐inferior line (PIL); and anterior line (AL). BDB rates of de novo ablation lines were 100% in circumferential pulmonary vein isolation, 100% in CTI, 84.7% in RL, 44.7% in PIL, and 63.6% in AL. During 29.0±18.4 months of follow‐up, 31.7% (126/398) of the patients showed clinical recurrence. Left atrial posterior wall (LAPW) isolation (BDBs of RL and PIL) was independently associated with lower clinical AF/atrial tachycardia recurrence (hazard ratio, 0.68; 95% CI, 0.47–0.98; P=0.041; log‐rank, P=0.017), whereas BDBs of RL or AL were not (log‐rank, P=0.178 for RL; P=0.764 for AL). Among 52 patients who underwent repeat procedures (23.0±16.1 months after de novo procedure), the BDB maintenance rates for CTI, RL, PIL, and AL were 94.2% (49 of 52), 63.5% (33 of 47), 62.1% (18 of 29), and 61.8% (21 of 34), respectively.

Conclusions: Although PIL crosses the esophageal contact area, LAPW isolation is important for better clinical outcome in catheter ablation with a linear ablation strategy for patients with persistent AF.

No MeSH data available.


Related in: MedlinePlus

A, Catheter Dallas lesion ablation set with electroanatomical activation map acquired during stable right atrial pacing revealing LAPW isolation without AL block. B, The same patient recurred as atrial tachycardia, and the redo mapping (activation map) 32 months after the index procedure shows focal tachycardia originated from LAPW and conducted to the anterior portion of LA through the reconnected RL. AL indicates anterior line; AT, atrial tachycardia; LAPW, left atrial posterior wall; RL, roof line.
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jah31809-fig-0001: A, Catheter Dallas lesion ablation set with electroanatomical activation map acquired during stable right atrial pacing revealing LAPW isolation without AL block. B, The same patient recurred as atrial tachycardia, and the redo mapping (activation map) 32 months after the index procedure shows focal tachycardia originated from LAPW and conducted to the anterior portion of LA through the reconnected RL. AL indicates anterior line; AT, atrial tachycardia; LAPW, left atrial posterior wall; RL, roof line.

Mentions: Details of the RFCA technique and strategy used in our center are described in our previous study.11 Briefly, we used an open irrigated‐tip catheter (Coolflex; 25–35 W, irrigation rate of 10–15 mL/min; St. Jude Medical) to deliver RF energy for ablation. All patients initially underwent CPVI and CTI ablation. RL, PIL, and AL6 were added as the standard lesion set, also known as the “Dallas lesion set” (Figure 1A). To generate the posterior box lesion, linear ablations of RL and PIL were made by connecting both sides of the CPVI at the top and bottom levels, respectively. AL was generated by ablation from the mitral annulus at the 12 o'clock position toward the LA RL.6 If atrial tachyarrhythmias could not be terminated by standard lesion set ablation, internal cardioversion and evaluation of BDB state were performed. BDB of RL was confirmed by differential pacing from LA appendage versus LA posterior wall (LAPW) and successful generation of PIL was considered to be achievement of LAPW isolation, which was defined as no endocardial electrogram in the LAPW with a setting of RL block and no capture of isolated LAPW pacing (Figure 1A). BDB of AL was confirmed by differential pacing from LA appendage versus LA septum.6 When BDB of linear ablation lines was not achieved, additional ablations were performed to achieve BDB of these lines. However, if BDB could not be achieved after 3 attempts of linear ablation, those lines were kept unblocked to avoid collateral damage. The operators could opt to perform additional ablations in the superior vena cava or non‐PV foci, or conduct complex fractionated electrograms12 at their discretion. If there were mappable AF triggers or atrial premature beats with isoproterenol infusion (5 μg/min), we carefully mapped and ablated those non‐PV foci as much as possible. All RFCA procedures were conducted according to the above specific protocol by 2 operators with more than 10 years of experience.


Challenging Achievement of Bidirectional Block After Linear Ablation Affects the Rhythm Outcome in Patients With Persistent Atrial Fibrillation
A, Catheter Dallas lesion ablation set with electroanatomical activation map acquired during stable right atrial pacing revealing LAPW isolation without AL block. B, The same patient recurred as atrial tachycardia, and the redo mapping (activation map) 32 months after the index procedure shows focal tachycardia originated from LAPW and conducted to the anterior portion of LA through the reconnected RL. AL indicates anterior line; AT, atrial tachycardia; LAPW, left atrial posterior wall; RL, roof line.
© Copyright Policy - creativeCommonsBy-nc
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC5121491&req=5

jah31809-fig-0001: A, Catheter Dallas lesion ablation set with electroanatomical activation map acquired during stable right atrial pacing revealing LAPW isolation without AL block. B, The same patient recurred as atrial tachycardia, and the redo mapping (activation map) 32 months after the index procedure shows focal tachycardia originated from LAPW and conducted to the anterior portion of LA through the reconnected RL. AL indicates anterior line; AT, atrial tachycardia; LAPW, left atrial posterior wall; RL, roof line.
Mentions: Details of the RFCA technique and strategy used in our center are described in our previous study.11 Briefly, we used an open irrigated‐tip catheter (Coolflex; 25–35 W, irrigation rate of 10–15 mL/min; St. Jude Medical) to deliver RF energy for ablation. All patients initially underwent CPVI and CTI ablation. RL, PIL, and AL6 were added as the standard lesion set, also known as the “Dallas lesion set” (Figure 1A). To generate the posterior box lesion, linear ablations of RL and PIL were made by connecting both sides of the CPVI at the top and bottom levels, respectively. AL was generated by ablation from the mitral annulus at the 12 o'clock position toward the LA RL.6 If atrial tachyarrhythmias could not be terminated by standard lesion set ablation, internal cardioversion and evaluation of BDB state were performed. BDB of RL was confirmed by differential pacing from LA appendage versus LA posterior wall (LAPW) and successful generation of PIL was considered to be achievement of LAPW isolation, which was defined as no endocardial electrogram in the LAPW with a setting of RL block and no capture of isolated LAPW pacing (Figure 1A). BDB of AL was confirmed by differential pacing from LA appendage versus LA septum.6 When BDB of linear ablation lines was not achieved, additional ablations were performed to achieve BDB of these lines. However, if BDB could not be achieved after 3 attempts of linear ablation, those lines were kept unblocked to avoid collateral damage. The operators could opt to perform additional ablations in the superior vena cava or non‐PV foci, or conduct complex fractionated electrograms12 at their discretion. If there were mappable AF triggers or atrial premature beats with isoproterenol infusion (5 μg/min), we carefully mapped and ablated those non‐PV foci as much as possible. All RFCA procedures were conducted according to the above specific protocol by 2 operators with more than 10 years of experience.

View Article: PubMed Central - PubMed

ABSTRACT

Background: It is not clear whether bidirectional block (BDB) of linear ablations reduces atrial fibrillation (AF) recurrence after radiofrequency catheter ablation. We hypothesized that BDB of linear ablation has prognostic significance after radiofrequency catheter ablation for persistent AF.

Methods and results: Among 1793 consecutive patients in the Yonsei AF ablation cohort, this observational cohort study included 398 patients with persistent AF (75.6% male; age, 59.8±10.3 years) who underwent catheter ablation with a consistent ablation protocol of the Dallas lesion set: circumferential pulmonary vein isolation; cavotricuspid isthmus ablation (CTI); roof line (RL); posterior‐inferior line (PIL); and anterior line (AL). BDB rates of de novo ablation lines were 100% in circumferential pulmonary vein isolation, 100% in CTI, 84.7% in RL, 44.7% in PIL, and 63.6% in AL. During 29.0±18.4 months of follow‐up, 31.7% (126/398) of the patients showed clinical recurrence. Left atrial posterior wall (LAPW) isolation (BDBs of RL and PIL) was independently associated with lower clinical AF/atrial tachycardia recurrence (hazard ratio, 0.68; 95% CI, 0.47–0.98; P=0.041; log‐rank, P=0.017), whereas BDBs of RL or AL were not (log‐rank, P=0.178 for RL; P=0.764 for AL). Among 52 patients who underwent repeat procedures (23.0±16.1 months after de novo procedure), the BDB maintenance rates for CTI, RL, PIL, and AL were 94.2% (49 of 52), 63.5% (33 of 47), 62.1% (18 of 29), and 61.8% (21 of 34), respectively.

Conclusions: Although PIL crosses the esophageal contact area, LAPW isolation is important for better clinical outcome in catheter ablation with a linear ablation strategy for patients with persistent AF.

No MeSH data available.


Related in: MedlinePlus