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Catheter ablation of chronic atrial fibrillation targeting the reinitiating triggers
M Haïssaguerre1, P Jaïs, D C Shah
1Hôpital Cardiologique du Haut-Lévêque, Bordeaux-Pessac, France.
Introduction:
We assessed the mode of reinitiation of atrial fibrillation (AF) after cardioversion and the efficacy of ablating these foci of reinitiation in patients with chronic AF.
Methods And Results:
Fifteen patients, 7 with structural heart disease, underwent mapping and catheter ablation of drug-resistant AF documented to be persistent for 5 +/- 4 months. In all patients, cardioversion was followed by documentation of P on T atrial ectopy and early recurrence, which allowed mapping of the reinitiating trigger or the source of ectopy. Radiofrequency (RF) ablation was performed at pulmonary vein (PV) ostia using a target temperature of 50 degrees C and a power limit of 30 to 40 W, with the endpoint being interruption of all local muscle conduction. A total of 32 arrhythmogenic PVs and 2 atrial foci (left septum and left appendage) were identified: 1, 2, and 3 or 4 PVs in 5, 3, and 6 patients. RF applications at the ostial perimeter resulted in progressively increasing delay, followed by abolition of PV potentials in 8, but potentials persisted in 6. A single ablation session was performed in 7 patients and 8 underwent two or three sessions because of recurrence of AF; ablation was directed at the same source due to recovery of local PV potential or at a different PV. No PV stenosis was noted either acutely or at repeated follow-up angiograms. Nine patients (60%) were in stable sinus rhythm without antiarrhythmic drugs at follow-up of 11 +/- 8 months. Anticoagulants were interrupted in 7 patients.
Conclusion:
PVs are the dominant triggers reinitiating chronic AF in this patient population. Elimination of PV potentials by ostial RF applications results in stable sinus rhythm in 60%. A larger group and longer follow-up are needed to investigate further the role of trigger ablation in curative therapy for chronic AF.
Insights
Pulmonary veins (PVs) commonly trigger atrial fibrillation (AF) recurrence after cardioversion. Ablating these PV triggers effectively restores sinus rhythm in 60% of patients with chronic AF.
Area of Science:
- Cardiology
- Electrophysiology
Background:
- Chronic atrial fibrillation (AF) often recurs after cardioversion.
- Identifying and ablating AF reinitiation triggers is crucial for effective treatment.
Purpose of the Study:
- To assess the triggers of atrial fibrillation (AF) reinitiation post-cardioversion.
- To evaluate the efficacy of ablating these triggers in patients with chronic AF.
Main Methods:
- Fifteen patients with drug-resistant chronic AF underwent mapping and radiofrequency (RF) ablation.
- Ablation targeted pulmonary vein (PV) ostia and identified atrial foci.
- The endpoint was the interruption of local muscle conduction.
Main Results:
- Cardioversion consistently led to P on T atrial ectopy and early AF recurrence.
- Arrhythmogenic sources included 32 PVs and 2 atrial foci.
- Pulmonary vein (PV) ostial ablation achieved stable sinus rhythm in 60% of patients at 11 months follow-up.
- No PV stenosis was observed.
Conclusions:
- Pulmonary veins (PVs) are primary triggers for chronic AF reinitiation.
- Ostial RF ablation of PV potentials provides sustained sinus rhythm in 60% of patients.
- Further research with larger cohorts and longer follow-up is warranted to confirm the curative role of trigger ablation in chronic AF.