Mechanisms of recurrent atrial fibrillation after pulmonary vein isolation by segmental ostial ablation☆
Section snippets
Study subjects
A repeat ablation procedure was offered to 76 patients who had recurrent episodes of paroxysmal AF during a mean follow-up of 7 ± 6 months after PV isolation by segmental ostial ablation. The 76 patients were part of a pool of 208 patients who underwent segmental ostial ablation. The subjects of this study were 50 of the 76 patients with recurrent AF who agreed to a repeat ablation procedure. Among the remaining 26 patients, 15 either had improvement in the frequency of episodes of AF or were
Recovery of conduction in a previously isolated PV
Among the 50 patients who underwent a repeat ablation procedure, there was recovery of conduction into ≥1 PV in 49 patients (98%). Among the 164 previously isolated PVs, recovery of conduction into a PV was observed in 40 (80%) of the 50 left superior PVs, 38 (76%) of the 50 right superior PVs, 28 (56%) of the 50 left inferior PVs, and 15 (75%) of the 20 right inferior PVs.
PV tachycardia
A PV tachycardia was present in ≥1 PV in 36 (72%) of the 50 patients during AF (Figure 1). PV tachycardias were observed
Main findings
The results of this study demonstrate that recovery of conduction into a previously isolated PV occurred in >95% of patients with recurrent AF after segmental ostial ablation for paroxysmal AF. However, PV tachycardias, which may play a role in the maintenance of AF, were observed in only 70% of patients. Freedom from recurrent AF after repeat PV isolation by segmental ostial ablation was dependent on the presence of PV tachycardias, whereas left atrial catheter ablation was effective
Conclusion
The findings of this study provide insight into the mechanisms of AF and explain why PV isolation by segmental ostial ablation is not effective in 30% to 40% of patients with paroxysmal AF. AF is a multifactorial process, and the PVs do not play a critical role in generating AF in all patients with paroxysmal AF. The efficacy of PV isolation by segmental ostial ablation depends on the presence of PV tachycardias during episodes of paroxysmal AF. In contrast, the efficacy of left atrial ablation
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Validation of lesion durability following pulmonary vein isolation using the new third-generation laser balloon catheter in patients with recurrent atrial fibrillation
2021, Journal of CardiologyCitation Excerpt :The main findings are: (1) an overall rate of durable PVI at the repeat procedure of 68.9%, (2) a higher rate durable PVI in EAS3 (82%) compared to EAS2 (61%), (3) a specific pattern of reconnection predominantly in RSPV irrespective of EAS generation, and (4) a higher reconnection rate when a reduced energy (5.5–7 W) was needed. AF recurrence is generally associated to electrical reconnection between the LA and PV [12]. Creating durable PV lesion sets is therefore crucial to improve long-term AF-free survival.
High-resolution mapping of pulmonary vein potentials improved the successful pulmonary vein isolation using small electrodes and inter-electrode spacing catheter
2018, International Journal of CardiologyCitation Excerpt :In almost all cases in which AF recurs after PVI, 1 or more of the PVs are found to have re-established electrical connection to the atria [2–4]. The pathological basis of PV reconnections is suspected to be caused by gaps in the line of ablation [5, 6], where resolution of edema or thermal stunning results in the recovery of the conduction properties of the injured, but still viable, myocardial tissue. It could also result from the failure to produce completely transmural lesions [7] or due to subsequent tissue remodeling.
Temperature-Controlled Radiofrequency Ablation for Pulmonary Vein Isolation in Patients With Atrial Fibrillation
2017, Journal of the American College of CardiologyAssociation between pulmonary vein orientation and ablation outcome in patients undergoing multi-electrode ablation for atrial fibrillation
2016, Journal of Cardiovascular Computed TomographyThe timing and frequency of pulmonary veins unexcitability relative to completion of a wide area circumferential ablation line for pulmonary vein isolation
2016, JACC: Clinical ElectrophysiologyCitation Excerpt :However, if the RFA line is anatomically completed by contiguous, high-quality RFA lesions, recovery of excitability of the PV sleeve alone would not result in electrical reconnection between PVs and the LA unless a lesion on the RFA line recovers excitability. Reported evidence of reconnection at gaps (3) and significant PV conduction recovery rates (14–19) supports the concept that transient injury both on the RFA line and within PV sleeves contribute to acute PVI when entrance and exit block are used as primary endpoints for PVI procedures. Alternative explanations for the observed phenomenon include PV ischemia or infarct, which may cause permanent unexcitability.
Pulmonary vein orientation assessment: Is it necessary in patients undergoing contact force sensing guided radiofrequency catheter ablation of atrial fibrillation
2015, IJC Heart and VasculatureCitation Excerpt :Hypothetically, pressure-guided ablation should allow the operator to identify inadequate lesions and apply additional ablations when deemed necessary. AF recurrences are generally regarded as reconnection between the PV and the LA allowing electrical reconduction [16,17]. Therefore the durability of the applied circumferential lesions are essential in preventing AF recurrences.
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Supported by the Ellen and Robert Thompson Atrial Fibrillation Research Fund.