Leonardo Arantes

Long-term follow-up of persistent atrial fibrillation ablation using termination as a procedural endpoint

AIMS Catheter ablation of long-lasting persistent atrial fibrillation (AF) has been performed with varying results using a combination of different techniques. Whether arrhythmia termination during ablation is associated with an improved clinical outcome is controversial. METHODS AND RESULTS In this prospective study, 153 consecutive patients (56 +/- 10 years) underwent catheter ablation of persistent AF (25 +/- 33 months) using a stepwise approach with the desired procedural endpoint being AF termination. Repeat ablation was performed for patients with recurrent AF or atrial tachycardia (AT) after a 1 month blanking period. A minimum follow-up of 12 months with repeated Holter monitoring was performed. Atrial fibrillation was terminated in 130 patients (85%). There was a lower incidence of AF in those patients in whom AF was terminated during the index procedure compared with those who had not (5 vs. 39% P < 0.0001, mean follow-up 32 +/- 11 months). Seventy-nine patients underwent repeat procedures: 64/130 in the termination group (6 AF, 58 AT) and 15 in the non-termination group (9 AF, 7 AT). After repeat ablation, sinus rhythm was maintained in 95% in whom AF was terminated compared with 52% in those in whom AF could not be terminated. CONCLUSION Procedural termination of long-lasting AF by catheter ablation alone is associated with an improved outcome.

Clinical Predictors of Termination and Clinical Outcome of Catheter Ablation for Persistent Atrial Fibrillation

OBJECTIVES This study evaluated the role of pre-procedural clinical variables to predict procedural and clinical outcomes of catheter ablation in patients with long-lasting persistent atrial fibrillation (AF). BACKGROUND Catheter ablation of persistent AF remains a challenging task. METHODS Catheter ablation was performed in 90 patients (76 men, age 57 +/- 11 years) with long-lasting persistent AF. The history of AF, echocardiographic parameters, presence of structural heart disease, and surface electrocardiogram (ECG) AF cycle length (CL) were assessed before ablation and analyzed with respect to procedural termination and clinical outcome. Mean follow-up was 28 +/- 4 months. RESULTS Persistent AF was terminated in 76 of 90 patients (84%) by ablation. The duration of continuous AF was shorter (p < 0.0001), the surface ECG AFCL was longer (p < 0.0001), and the left atrium was smaller (p < 0.01) in patients in whom AF was terminated by catheter ablation. The surface ECG AFCL was the only independent predictor of AF termination (p < 0.01). Maintenance of sinus rhythm was associated with a shorter duration of continuous AF (p < 0.0001), a longer surface ECG AFCL (p < 0.001), and a smaller left atrium (p < 0.05) compared with those with recurrent arrhythmia. In multivariate analysis, the surface ECG AFCL and the AF duration predicted clinical success of persistent AF ablation (p < 0.01 and p < 0.05, respectively). CONCLUSIONS The surface ECG AFCL is a clinically useful pre-ablation tool for predicting patients in whom sinus rhythm can be restored by catheter ablation. The duration of continuous AF and the surface ECG AFCL are predictive of maintenance of sinus rhythm.

Peri-mitral atrial flutter in patients with atrial fibrillation ablation

BACKGROUND Peri-mitral atrial flutter (PMFL) is commonly encountered in patients undergoing atrial fibrillation (AF) ablation. OBJECTIVE The purpose of this study was to determine the electrophysiologic characteristics, procedural success, and medium-term outcomes in patients with PMFL. METHODS The study consisted of 50 consecutive patients (45 men and 5 women, age 57 +/- 12 years) with PMFL following or during AF ablation. Of the 50 PMFLs, 24 occurred during AF ablation (16 at index ablation and 8 at repeat procedure for recurrent AF), and 26 developed during follow-up. Ablation of PMFL was performed by creating a linear lesion joining the mitral annulus to the left inferior pulmonary vein. RESULTS The incidence of PMFL was higher in patients with mitral isthmus (MI) ablation performed during AF ablation, prior to the development of PMFL, than in those in whom MI ablation was not performed (23% vs 8%, P = .04). Following the procedure, PMFL was more frequent in patients with prior MI ablation than in those without (41% vs 15%, P <.01). Seventy percent (35/50) were terminated by ablation with 6.4 +/- 6.9 minutes of radiofrequency application. Among patients in whom PMFL terminated, supplemental ablation was required for bidirectional conduction block in 66% (23/35). MI block was achieved in 92% (46/50) using 13.6 +/- 7.4 minutes of ablation. At mean follow-up of 19 +/- 4 months, 96% of patients were free from PMFL. CONCLUSION PMFL can be terminated by MI ablation, but the procedure is proarrhythmic. Supplemental ablation is necessary to establish bidirectional block of the line despite termination of PMFL in the majority of patients.

Impact of Catheter Ablation of the Coronary Sinus on Paroxysmal or Persistent Atrial Fibrillation

Objectives: This study evaluated the impact of catheter ablation of the coronary sinus (CS) region during paroxysmal and persistent atrial fibrillation (AF).

Focal Arrhythmia Confined Within the Coronary Sinus and Maintaining Atrial Fibrillation

Introduction: The coronary sinus (CS) is a complex structure comprising a mesh of circumferential muscular fibers with oblique connections to both atria. We describe further evidence for the clinical importance of CS arrhythmogenicity in maintaining atrial fibrillation (AF) in humans.

Catheter ablation of persistent and permanent atrial fibrillation: Bordeaux experience.

The seminal observation that ectopics from the pulmonary veins may initiate paroxysmal atrial fibrillation (AF) heralded an era of potentially curative catheter ablation therapy for AF. In recent years, catheter ablation has been performed for not only paroxysmal but also persistent and permanent AF. It is anticipated that the number of procedures will continue to increase and the indication for catheter ablation will expand. This article details our experience with catheter ablation therapy for patients with persistent and chronic AF.

Tachycardia Transition During Ablation of Persistent Atrial Fibrillation

Tachycardia Transition. Background: The “sequential ablation” strategy for persistent AF is aimed at progressive organization of AF until the rhythm converts to sinus rhythm or atrial tachycardia (AT). During ablation of an AT, apparently seamless transitions from one organized AT to another occur. The purpose of our study was to quantify the occurrence and the mechanism of this transition.

Cycle length dependent block in the "mitral-pulmonary vein" isthmus

We report a case of cycle length dependent activation sequence in the coronary sinus catheter during assessment of mitral‐pulmonary vein isthmus block. A 61‐year‐old patient presented with atrial tachycardia following a recent pulmonary vein isolation for paroxysmal atrial fibrillation. A perimitral macroreentrant atrial tachycardia was demonstrated during mapping. The isthmus block observed following initial ablation of the mitral‐pulmonary vein appeared to be pacing cycle dependent and to our knowledge has not been previously described.

Dual Independent Atrial Tachycardias After Ablation of Chronic Atrial Fibrillation

We report the case of a 71‐year‐old man with two atrial tachycardias evolving simultaneously and independently in two dissociated regions after extensive ablation for chronic atrial fibrillation. One tachycardia was a focal tachycardia originating from the right inferior pulmonary vein and activating the posterior left atrium with a 2:1 conduction block, while the other tachycardia was an atrial flutter circulating around the tricuspid annulus, activating the right atrium and the anterior wall of the left atrium. These two atrial tachycardias were successfully ablated prior to restoration of sinus rhythm.

Left Atrial Appendage Activity Mimicking an Epsilon Wave on the Surface Electrocardiogram

Figure 1. Surface electrocardiogram and intracardiac electrogram showing one bipole of the Lasso catheter inside the LAA. (A) Late LAA activity on time with small wave after QRS (B) LAA activity merges with ventricular activity after a pause and the small wave disappears. ∗ marks the small wave after the QRS on time with the LAA potential marked by •. RFp = radiofrequency proximal bipole (located at the junction between LAA and Left atrium); LAA = left atrial appendage; II, aVR, aVF, V6–ECG surface leads (The gain at the surface ECG is 16 and on the intracardiac eletrogram is 4.)