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Echocardiographically guided left atrial ablation: characterization of a new technique
David Schwartzman1, John Nosbisch, Debra Housel
1Cardiovascular Institute, University of Pittsburgh, Pennsylvania 15213, USA. schwartzmand@upmc.edu
Background:
Several techniques for percutaneous catheter-based radiofrequency ablation of left atrial myocardium have been described. Each is potentially limited by anatomic inaccuracy, radiation requirement, cardiac/extracardiac collateral damage, proarrhythmia, lesion impermanence, or unclear procedural endpoint.
Objectives:
The purpose of this study was to describe a new technique that may address some of these limitations.
Methods:
In 200 consecutive patients with atrial fibrillation (AF), complete ablative encircling of right and left pulmonary venous vestibules was performed using radiofrequency energy applied via a standard ablation electrode. Lesions were guided by a collaborative nonfluoroscopic imaging strategy involving intra-left atrial echocardiography and CARTO. A discrete procedural endpoint was sought: complete electrical isolation of all myocardium subtended by the encircling lesions.
Results:
After a procedure in which the total fluoroscopy time averaged 6 minutes, isolation was achieved on the left and right sides in 198 and 199 patients, respectively. In addition to the vestibule-encircling lesions, isolation required one or more additional focal lesions within the subtended myocardial territory in the majority of left vestibules and in a minority of right vestibules. Significant procedural morbidity was observed, including cerebroembolism resulting in death and mesenteric embolism resulting in hemicolectomy. Procedural success, defined at 2 years after the initial procedure and requiring no interim procedure, antiarrhythmic drug therapy, or apparent arrhythmia burden, was observed in a significantly greater proportion of patients with a paroxysmal (87%) than persistent AF (60%) syndrome. Only a small proportion of patients with recurrent AF had recurrence of conduction in previously isolated zones.
Conclusion:
This technique may have advantages over those previously reported, including improved anatomic accuracy, improved lesion safety and efficacy, and diminished radiation exposure.
