PV Isolation (pv + isolation)

Distribution by Scientific Domains


Selected Abstracts


Triggering Pulmonary Veins: A Paradoxical Predictor for Atrial Fibrillation Recurrence After PV Isolation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2010
YVES DE GREEF M.D.
Triggering Pulmonary Veins and Recurrence After Ablation.,Purpose: To identify procedural parameters predicting recurrence of atrial fibrillation (AF) after a first circumferential pulmonary vein isolation (CPVI). Methods: One hundred seventy-one patients undergoing CARTO-guided CPVI for recurrent AF with a left atrial (LA) diameter <45 mm were studied. Follow-up (symptoms and 7-day Holter) was performed at 1 and 3 months and every 3 months thereafter. Clinical and procedural characteristics between successful patients and patients undergoing repeat ablation were compared. In addition, procedural parameters of the first procedure were compared with parameters during repeat ablation. Results: After first CPVI, 80% of patients were free of AF without antiarrhythmic drugs after a follow-up (FU) of 28 ± 11 months (N = 136). Thirty-five patients (20%) had recurrence of AF of which 25 underwent repeat ablation (N = 25). Clinical characteristics did not differ between the successful and repeat group. A triggering vein during the index procedure was significantly more observed in the repeat group (56% vs 11%, P < 0.001). At repeat ablation, 2.6 ± 1.2 veins per patient were reconnected. Whereas there was no preferential reconnecting PV, all PVs triggering at index were reconnected (100%). Conclusions: (1) In patients with symptomatic recurrent AF, the presence of a triggering pulmonary vein during ablation is a paradoxical predictor for AF recurrence after PV isolation. (2) The consistent finding of reconnection of the triggering PV at repeat ablation, suggests that, in these patients, the triggering PV is the culprit vein and that reconnection invariably results in clinical AF recurrence. (3) The present study advocates a strategy of even more stringent PV isolation in case of a triggering PV. (J Cardiovasc Electrophysiol, Vol. 21, pp. 381,388, April 2010) [source]


The Permanency of Pulmonary Vein Isolation Using a Balloon Cryoablation Catheter

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 7 2010
HUMERA AHMED B.A.
Chronic PV Isolation With the Cryoballoon.,Background: Because of its technical feasibility and presumed safety benefits, balloon cryoablation is being increasingly employed for pulmonary vein (PV) isolation. While acute isolation has been demonstrated in most patients, little data are available on the chronic durability of cryoballoon lesions. Methods and Results: Twelve atrial fibrillation patients underwent PV isolation using either a 23-mm or 28-mm cryoballoon. For each vein, after electrical isolation was verified with the use of a circular mapping cathether, 2 bonus balloon ablation lesions were placed. Gaps in balloon occlusion were overcome using either a spot cryocatheter or a "pull-down" technique. A prespecified second procedure was performed at 8,12 weeks to assess for long-term PV isolation. Acute PV isolation was achieved in all PVs in the patient cohort (n = 48 PVs), using the cryoballoon alone in 47/48 PVs (98%); a "pull-down" technique was employed for 5 PVs (1 right superior pulmonary vein, 2 right inferior pulmonary veins, and 2 left inferior pulmonary veins). The gap in the remaining vein was ablated with a spot cryocatheter. During the second mapping procedure, 42 of 48 PVs (88%) remained isolated. One vein had reconnected in 2 patients, while 2 veins had reconnected in another 2 patients. All PVs initially isolated with the "pull-down" technique remained isolated at the second procedure. Conclusions: Cryoballoon ablation allows for durable PV isolation with the use of a single balloon. With maintained chronic isolation in most PVs, it may represent a significant step toward consistent and lasting ablation procedures. (J Cardiovasc Electrophysiol, Vol. pp. 731-737, July 2010) [source]


Triggering Pulmonary Veins: A Paradoxical Predictor for Atrial Fibrillation Recurrence After PV Isolation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2010
YVES DE GREEF M.D.
Triggering Pulmonary Veins and Recurrence After Ablation.,Purpose: To identify procedural parameters predicting recurrence of atrial fibrillation (AF) after a first circumferential pulmonary vein isolation (CPVI). Methods: One hundred seventy-one patients undergoing CARTO-guided CPVI for recurrent AF with a left atrial (LA) diameter <45 mm were studied. Follow-up (symptoms and 7-day Holter) was performed at 1 and 3 months and every 3 months thereafter. Clinical and procedural characteristics between successful patients and patients undergoing repeat ablation were compared. In addition, procedural parameters of the first procedure were compared with parameters during repeat ablation. Results: After first CPVI, 80% of patients were free of AF without antiarrhythmic drugs after a follow-up (FU) of 28 ± 11 months (N = 136). Thirty-five patients (20%) had recurrence of AF of which 25 underwent repeat ablation (N = 25). Clinical characteristics did not differ between the successful and repeat group. A triggering vein during the index procedure was significantly more observed in the repeat group (56% vs 11%, P < 0.001). At repeat ablation, 2.6 ± 1.2 veins per patient were reconnected. Whereas there was no preferential reconnecting PV, all PVs triggering at index were reconnected (100%). Conclusions: (1) In patients with symptomatic recurrent AF, the presence of a triggering pulmonary vein during ablation is a paradoxical predictor for AF recurrence after PV isolation. (2) The consistent finding of reconnection of the triggering PV at repeat ablation, suggests that, in these patients, the triggering PV is the culprit vein and that reconnection invariably results in clinical AF recurrence. (3) The present study advocates a strategy of even more stringent PV isolation in case of a triggering PV. (J Cardiovasc Electrophysiol, Vol. 21, pp. 381,388, April 2010) [source]


Characteristics of Complex Fractionated Electrograms in Nonpulmonary Vein Ectopy Initiating Atrial Fibrillation/Atrial Tachycardia

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 12 2009
LI-WEI LO M.D.
Background: Nonpulmonary vein (PV) ectopy initiating atrial fibrillation (AF)/atrial tachycardia (AT) is not uncommon in patients with AF. The relationship of complex fractionated atrial electrograms (CFAEs) and non-PV ectopy initiating AF/AT has not been assessed. We aimed to characterize the CFAEs in the non-PV ectopy initiating AF/AT. Methods: Twenty-three patients (age 53 ± 11 y/o, 19 males) who underwent a stepwise AF ablation with coexisting PV and non-PV ectopy initiating AF or AT were included. CFAE mapping was applied before and after the PV isolation in both atria by using a real-time NavX electroanatomic mapping system. A CFAE was defined as a fractionation interval (FI) of less than 120 ms over 8-second duration. A continuous CFAE (mostly, an FI < 50 ms) was defined as electrogram fractionation or repetitive rapid activity lasting for more than 8 seconds. Results: All patients (100%) with non-PV ectopy initiating AF or AT demonstrated corresponding continuous CFAEs at the firing foci. There was no significant difference in the FI among the PV ostial or non-PV atrial ectopy or other atrial CFAEs (54.1 ± 5.6, 58.3 ± 11.3, 52.8 ± 5.8 ms, P = 0.12). Ablation targeting those continuous CFAEs terminated the AF and AT and eliminated the non-PV ectopy in all patients (100%). During a follow-up of 7 months, 22% of the patients had an AF recurrence with PV reconnections. There was no recurrence of any ablated non-PV ectopy during the follow-up. Conclusion: The sites of the origin of the non-PV ectopies were at the same location as those of the atrial continuous CFAEs. Those non-PV foci were able to initiate and sustain AF/AT. By limited ablation targeting all atrial continuous CFAEs, the AF could be effectively eliminated. [source]


Does Left Atrial Volume and Pulmonary Venous Anatomy Predict the Outcome of Catheter Ablation of Atrial Fibrillation?

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 9 2009
IRENE HOF M.D.
Introduction: Preprocedural factors may be helpful in selecting patients with atrial fibrillation (AF) for treatment with catheter ablation and in making an assumption regarding their prognosis. The aims of this study were to investigate whether left atrial (LA) volume and pulmonary venous (PV) anatomy, evaluated by computed tomography (CT) prior to ablation, will predict AF recurrence following catheter ablation. Methods and Results: We included 146 patients (mean age 57 ± 11 years, 83% male) with symptomatic AF (55% paroxysmal, 18% persistent, 27% long-standing persistent). All patients underwent CT scanning prior to catheter ablation to evaluate LA volume and PV anatomy. Circumferential PV isolation was performed guided by Cartomerge electroanatomical mapping. The outcome was defined as complete success, improvement, or failure. After a mean follow-up of 19 ±7 months, complete success was achieved in 59 patients (40%), and 38 patients (26%) demonstrated improvement. LA volume was found to be an independent predictor of AF recurrence with an adjusted OR of 1.14 for every 10-mL increase in volume (95% CI 1.00,1.29, P = 0.047). PV variations were equally distributed among the different outcomes of the ablation procedure, and therefore univariate analysis did not identify PV anatomy as a predictor of outcome. Conclusion: LA volume is an independent predictor of AF recurrence after catheter ablation. Additionally, PV anatomy did not have any effect on the outcome. These findings suggest that an assessment of LA volume may be incorporated into the preprocedural evaluation of patients being considered for AF ablation. [source]


First Experiences for Pulmonary Vein Isolation with the High-Density Mesh Ablator (HDMA): A Novel Mesh Electrode Catheter for Both Mapping and Radiofrequency Delivery in a Single Unit

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2009
AXEL MEISSNER M.D.
Background: Interventional therapy of atrial fibrillation (AF) is often associated with long examination and fluoroscopy times. The use of mapping catheters in addition to the ablation catheter requires multiple transseptal sheaths for left atrial access. Objectives: The purpose of this prospective study was to evaluate feasibility and safety of pulmonary vein (PV) isolation using the high-density mesh ablator (HDMA), a novel single, expandable electrode catheter for both mapping and radiofrequency (RF) delivery at the left atrium/PV junctions. Methods: Twenty-six patients with highly symptomatic paroxysmal AF (14, 53.8%) and persistent AF (12, 46.2%) were studied. Segmental PV isolation via the HDMA was performed using a customized pulsed RF energy delivery program (target temperature 55,60°C, power 70,100 W, 600,900 seconds RF application time/PV). Results: All 104 PVs in 26 patients could be ablated by the HDMA. Segmental PV isolation was achieved with a mean of 3.25 ± 1.4 RF applications for a mean of 603 ± 185 seconds. Entrance conduction block was obtained in 94.2% of all PV. The mean total procedure and fluoroscopy time was 159.0 ± 32 minutes and 33.5 ± 8.6 minutes, respectively. None of the patients experienced severe acute complications. After 3 months no PV stenosis was observed, and 85.6% and 41.6% of the patients with PAF and persistent AF, respectively, did not report symptomatic AF. Conclusions: In this first study of PV isolation using the HDMA, our findings suggest that this method is safe and yields good primary success rates. The HDMA simplifies AF ablation, favorably impacting procedure and fluoroscopy times. [source]


Clinical Experience with a Single Catheter for Mapping and Ablation of Pulmonary Vein Ostium

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2009
PAOLO DE FILIPPO M.D.
Introduction: The aim of this single center study is to evaluate the safety and the efficacy of performing pulmonary vein isolation (PVI) using a single high-density mesh ablator (HDMA) catheter. Methods: A total of 17 consecutive patients with paroxysmal (10 patients) or persistent atrial fibrillation (7 patients) and no heart disease were enrolled. A single transseptal puncture was performed and the HDMA was placed at each PV ostium identified with anatomic and electrophysiological mapping. Pulsed radiofrequency (RF) energy was delivered at the targeted temperature of 58°C with maximum power of 80 watts. No other ablation system was utilized. The primary objective of the study was acute isolation of the targeted PV, and the secondary objective was clinical efficacy and safety of PVI with HDMA for atrial fibrillation (AF) prevention. Patients were followed at intervals of 1, 3, 6, and 12 months. Results: PVI was attempted with HDMA in 67/67 PVs. [Correction made after online publication October 27, 2008: PVs changed from 6/67 to 67/67] Acute success rate were: 100% (16/16) for left superior PV, 100% (16/16) for left inferior PV, 100% (17/17) for right superior PV, 100% (1/1) for left common trunk and 47% (8/17) for right inferior PV. Total procedure time was 200 ± 36 minutes (range 130,240 minutes) and total fluoroscopy time was 42 ± 18 minutes (range 23,75 minutes). During a mean follow-up of 11 ± 4 months, 64% of patients remained in sinus rhythm (8/10 paroxysmal AF and 3/7 for persistent AF). No complications occurred either acutely or at follow-up. Conclusions: PV isolation with HDMA is feasible and safe. The midterm efficacy in maintaining sinus rhythm is higher in paroxysmal than in persistent patients. [source]


Safe and Effective Ablation of Atrial Fibrillation: Importance of Esophageal Temperature Monitoring to Avoid Periesophageal Nerve Injury as a Complication of Pulmonary Vein Isolation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 1 2009
TAISHI KUWAHARA M.D.
Introduction: Catheter ablation on the left atrial posterior wall has been reported to potentially damage the esophagus or periesophageal vagal nerve. The aim of this study was to evaluate the efficacy of esophageal temperature monitoring (ETM) in preventing esophageal or periesophageal vagal nerve injury in patients with atrial fibrillation (AF) undergoing pulmonary vein (PV) isolation. Methods: This study included 359 patients with drug-refractory AF who underwent extensive PV isolation. The first 152 patients were treated without ETM (non-ETM) and the last 207 with ETM. In the ETM group, the esophageal temperature (ET) was measured with a deflectable temperature probe that was placed close to the ablation electrode, and the radiofrequency energy applications were stopped when the ET reached 42°C. Results: In all patients in the ETM group, the ET increased to 42°C in at least one site by 28 ± 14 seconds, mostly along the right side of the left PVs, especially near the left inferior PV. Less energy (6.3 ± 1.9 × 104 J) was required for PV isolation in the ETM group than that in the non-ETM (6.8 ± 1.9 ×104 J, P = 0.03). Gastric hypomotility owing to periesophageal nerve damage was observed in three patients in the non-ETM group, but in none in the ETM (P = 0.02). The recurrence rates of AF did not differ between the two groups (non-ETM, 29%; ETM, 27%). Conclusion: Titration of the duration of the ablation energy delivery while monitoring the ET could prevent periesophageal nerve injury due to the AF ablation, without decreasing the success rate of maintaining sinus rhythm. [source]


Radiofrequency Catheter Ablation of Atrial Fibrillation in Athletes Referred for Disabling Symptoms Preventing Usual Training Schedule and Sport Competition

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 5 2008
FRANCESCO FURLANELLO M.D.
Introduction: Atrial fibrillation (AF) may occasionally affect athletes by impairing their ability to compete, and leading to noneligibility at prequalification screening. The impact of catheter ablation (CA) in restoring full competitive activity of athletes affected by AF is not known. The aim of our study was to investigate the effectiveness of CA of idiopathic AF in athletes with palpitations impairing physical performance and compromising eligibility for competitive activities. Methods and Results: Twenty consecutive competitive athletes (all males; 44.4 ± 13.0 years) with disabling palpitations on the basis of idiopathic drug-refractory AF underwent 46 procedures (2.3 ± 0.4 per patient) according to a prospectively designed multiprocedural CA approach that consolidates pulmonary veins (PV) isolation through subsequent steps. Preablation, effort-induced AF could be documented in 13 patients (65%) during stress ECG and significantly reduced maximal effort capacity (176 ± 21 W), as compared with patients with no AF during effort (207 ± 43 W, P < 0.05). At the end of CA protocol, which also included ablation of atrial flutter (AFL) in 7 patients, 18 (90.0%) patients were free of AF and two (10.0%) reported short-lasting (minutes) episodes of palpitations during 36.1 ± 12.7 months follow-up. Compared with preablation, postablation maximal exercise capacity significantly improved (from 183 ± 32 to 218 ± 20 W, P < 0.02). All baseline quality of life (QoL) parameters pertinent to physical activity significantly improved (P < 0.05) at the end of CA protocol. All athletes obtained reeligibility and could effectively reinitiate sport activity. Conclusions: AF, alone or in combination with AFL, may significantly impair maximal effort capacity thereby limiting competitive performance. Multiple PV isolation proved very effective in these patients to restore full competitive activity and allow reeligibility. [source]


Pain and Anatomical Locations of Radiofrequency Ablation as Predictors of Esophageal Temperature Rise During Pulmonary Vein Isolation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 1 2008
ARASH ARYANA M.D.
Introduction: Esophageal temperature rise (ETR) during ablation inside left atrium has been reported as a marker for esophageal thermal injury. We sought to investigate the possible relationships between chest pain and ETR during radiofrequency (RF) ablation, and ETR and locations of RF application, in patients undergoing pulmonary vein (PV) isolation under moderate sedation. Methods and Results: We analyzed anatomical locations of each RF application and its association with esophageal temperature and presence/absence of pain. Data from 40 consecutive patients (mean age: 56 ± 10 years) were analyzed. There were a total of 4,071 RF applications resulting in 291 episodes of pain (7.1%) and 223 ETRs (5.5%). Thirty-five patients (87.5%) experienced at least one pain episode and 32 (80.0%) had at least one ETR. While 77.4% of posterior wall applications that caused pain also corresponded to an ETR (P < 0.0001), only 0.8% of pain-free posterior wall applications were associated with ETRs (P < 0.0001). The sensitivity and specificity of pain during ablation for ETR were 94% and 98%, respectively. No ETRs were observed during anterior wall applications. ETRs occurred more frequently during ablation on the left (86.1%) versus the right (13.9%), and in inferior (70.4%) versus superior (29.6%) segments. Conclusion: In patients undergoing PV isolation, ETR was encountered when ablating in the posterior left atrium with the distribution left > right and inferior > superior. Pain during ablation was associated with ETR, and lack of pain was strongly associated with absence of ETR. Pain during RF ablation may thus serve as a predictor of esophageal heating and potential injury. [source]


Mechanisms of Recurrent Atrial Fibrillation: Comparisons Between Segmental Ostial Versus Circumferential Pulmonary Vein Isolation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 8 2007
LI-WEI LO M.D.
Background: Electrical isolation of pulmonary veins (PVs) is an effective therapy for atrial fibrillation (AF). Both segmental ostial PV ablation and circumferential ablation with PV,left atrial (LA) block have been implicated to eliminate AF. However, the mechanism of the recurrent AF after undergoing either strategy remains unclear. Methods and Results: Of the 73 consecutive patients with symptomatic AF that underwent PV isolation and had recurrences of AF, Group 1 consisted of 46 patients (age 56 ± 13 years old, 35 males) who underwent PV isolation by segmental ostial PV ablation and Group 2 consisted of 27 patients (age 51 ± 11 years old, 24 males) who underwent circumferential ablation with PV,LA block. In Group 1, the earliest ectopic beat or ostial PV potentials were targeted. In Group 2, circumferential ablation with PV,LA block was performed by encircling the extraostial regions around the left and right PVs. During the first procedure, all patients had PV,AF. There was no difference in the non-PV ectopy between Group 1 and Group 2. During the second procedure, the incidence of an LA posterior wall ectopy initiating AF was significantly lower (20% vs. 0%, P = 0.01) in Group 2. There was no difference in the PV ectopy initiating AF during the second procedure. Conclusion: Circumferential ablation of AF with PV,LA block may eliminate the LA posterior wall ectopy and decrease the incidence of LA posterior wall ectopy initiating AF during the second procedure. [source]


Achievement of Pulmonary Vein Isolation in Patients Undergoing Circumferential Pulmonary Vein Ablation: A Randomized Comparison Between Two Different Isolation Approaches

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 12 2006
XINGPENG LIU M.D.
Introduction: Circumferential pulmonary vein ablation (CPVA) with the endpoint of pulmonary vein (PV) isolation has been developed as an effective therapy for atrial fibrillation (AF). This endpoint can be achieved either by closing gaps along circular lines or by segmental PV isolation inside the circular lines after creation of initial CPVA lesions. We investigated whether the clinical outcome depends on the PV isolation approach used during the first-time CPVA procedure. Methods and Results: One hundred consecutive patients (69 male; age, 56.7 ± 11.6 years) who underwent first-time CPVA for treatment of symptomatic AF were enrolled. PV isolation was randomly achieved either by CPVA alone (aggressive CPVA [A-CPVA] group, n = 50) or by a combination of CPVA with segmental PV ostia ablation (modified CPVA [M-CPVA] group, n = 50). Recurrence of atrial tachyarrhythmias (ATa) within 3 months after the initial procedure occurred in 30 patients (60%) in the M-CPVA group and in only 15 patients (30%) in the A-CPVA group (P < 0.01). ATa relapse after the first 3 months was detected in 21 patients (42%) in the M-CPVA group, compared with 9 patients (18%) in the A-CPVA group (P = 0.01). At 13 ± 4 months, patients treated by the A-CPVA approach had greater freedom from ATa recurrence than patients who underwent M-CPVA (P = 0.01). The M-CPVA approach was the only independent predictor associated with procedural failure (RR 0.318; 95% CI 0.123,0.821; P = 0.02). Conclusions: When PV isolation is the endpoint of CPVA, the efficacy of the A-CPVA approach is better than that of M-CPVA. [source]


The Mechanisms of Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 2006
PENG-SHENG CHEN M.D.
In this article we have reviewed the mechanisms of atrial fibrillation (AF) with special emphasis on the thoracic veins. Based on a number of features, the thoracic veins are highly arrhythmogenic. The pulmonary vein (PV)-left atrial (LA) junction has discontinuous myocardial fibers separated by fibrotic tissues. The PV muscle sleeve is highly anisotropic. The vein of Marshall (VOM) in humans has multiple small muscle bundles separated by fibrosis and fat. Insulated muscle fibers can promote reentrant excitation, automaticity, and triggered activity. The PV muscle sleeves contain periodic acid-Schiff (PAS)-positive large pale cells that are morphologically reminiscent of Purkinje cells. These special cells could be the sources of focal discharge. Antiarrhythmic drugs have significant effects on PV muscle sleeves both at baseline and during AF. Both class I and III drugs have effects on wavefront traveling from PV to LA and from LA to PV. Separating the thoracic veins and the LA with ablation techniques also prevents PV-LA interaction. By reducing PV-LA interaction, pharmacological therapy and PV isolation reduce the activation rate in PV, intracellular calcium accumulation, and triggered activity. Therefore, thoracic vein isolation is an important technique in AF control. We conclude that thoracic veins are important in the generation and maintenance of AF. [source]


A Single Pulmonary Vein as Electrophysiological Substrate of Paroxysmal Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 11 2006
HE HUANG M.D.
Introduction: It has been demonstrated that pulmonary veins (PVs) play an important role in initiation and maintenance of paroxysmal atrial fibrillation (AF). However, it is not clearly known whether a single PV acts as electrophysiological substrate for paroxysmal AF. Methods and Results: This study included five patients with paroxysmal AF. All patients underwent complete PV isolation with continuous circular lesions (CCLs) around the ipsilateral PVs guided by a three-dimensional mapping system. Irrigated radiofrequency (RF) delivery was performed during AF on the right-sided CCLs in two patients and on the left-sided CCLs in three patients. The incomplete CCLs resulted in a change from AF to atrial tachycardia (AT), which presented with an identical atrial activation sequence and P wave morphology. Complete CCLs resulted in AF termination with persistent PV tachyarrhythmias within the isolated PV in all five patients. PV tachyarrhythmia within the isolated PV was PV fibrillation from the left common PV (LCPV) in two patients, PV tachycardia from the right superior PV (RSPV) in two patients, and from the left superior PV in one patient. All sustained PV tachyarrhythmias persisted for more than 30 minutes, needed external cardioversion for termination in four patients and a focal ablation in one patient. After the initial procedure, an AT from the RSPV occurred in a patient with PV fibrillation within the LCPV, and was successfully ablated. Conclusion: In patients with paroxysmal AF, sustained PV tachyarrhythmias from a single PV can perpetuate AF. Complete isolation of all PV may provide good clinical outcome during long-term follow-up. [source]


Assessment of Pulmonary Vein Anatomic Variability by Magnetic Resonance Imaging:

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 4 2004
Implications for Catheter Ablation Techniques for Atrial Fibrillation
Introduction: Pulmonary vein (PV) isolation for atrial fibrillation (AF) currently is performed using either an ostial or an extra-ostial approach. The objective of this study was to analyze by three-dimensional (3D) magnetic resonance angiography (MRA) the anatomy of the PVs in order to detect structural variability that would impact the choice of ablation approach. Methods and Results: Three-dimensional MRA was performed in 105 patients undergoing PV isolation. The ostial diameter, branching pattern, and PV angulation were analyzed. Fifty-nine (56%) patients had the typical pattern of 4 PVs with 4 separate ostia, 30 (29%) patients had an additional PV, and 18 (17%) patients had a left common PV trunk. In two patients, there were three right-sided veins and a common left-sided trunk, giving rise to four ostia: three on the right and one on the left. Two different populations of right middle PVs were noted: one where the additional vein projected anteriorly to drain the right middle lobe and one posterior to drain the superior portion of the right lower lobe. The average intrapatient variability in PV diameter was 7.9 ± 4.2 mm. The PV ostium was <10 mm in 26 (25%) patients and >25 mm in 15 (14%) patients. The first branch originated 6.7 ± 2.3 mm from the ostium. The left superior, right superior, right inferior, and left inferior PVs were found to enter the left atrium at the following angles: 32 ± 13°, 131 ± 11°, 206 ± 16°, and 329 ± 14°, respectively. Forty-nine patients (47%) had at least one funnel shaped PV. Conclusion: This largest PV imaging study to date demonstrates that MRA is a valuable tool that allows detection of marked intrapatient and interpatient anatomic variability of the PVs. These findings suggest that, at least in some patients, circumferential extra-ostial left atrial encirclement of the PVs may be preferable to ostial PV isolation. These findings also may have significant implications on the future development of coil- and balloon-based catheter ablation designs for AF ablation. (J Cardiovasc Electrophysiol, Vol. 15, pp. 387-393, April 2004) [source]


Usefulness of a New Radiofrequency Thermal Balloon Catheter for Pulmonary Vein Isolation:

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 6 2003
A New Device for Treatment of Atrial Fibrillation
Introduction: A rapidly firing or triggered ectopic focus located within a pulmonary vein (PV) or close to the PV ostium could induce atrial fibrillation (AF). The aim of this study was to evaluate the efficacy and safety of a radiofrequency thermal balloon catheter for isolation of the PV from the left atrium (LA). Methods and Results: Twenty patients with drug-resistant paroxysmal AF were treated by isolating the superior PVs using an RF thermal balloon catheter. Using a transseptal approach, the balloon, which had an inflated diameter 5 to 10 mm larger than that of the PV ostium, was wedged at the LA-PV junction. It was heated by a very-high-frequency current (13.56 MHZ) applied to the coil electrode inside the balloon for 2 to 3 minutes, and the procedure was repeated up to four times. The balloon center temperature was maintained at 60° to 75°C by regulating generator output. Successful PV isolation was achieved in 19 of the 20 left superior PVs and in all 20 of the right superior PVs and was associated with a decrease in amplitude of the ostial potentials. Total procedure time was1.8 ± 0.5hours, which included22 ± 7minutes of fluoroscopy time. After a follow-up period of8.1 ± 0.8months, 17 patients were free from AF, with 10 not taking any antiarrhythmic drugs and 7 taking the same antiarrhythmic agent as before ablation. Electron beam computed tomography revealed no complications, such as PV stenosis at ablation sites. Conclusion: The PV and its ostial region can be safely and quickly isolated from the LA by circumferential ablation around the PV ostia using a radiofrequency thermal balloon catheter for treatment of AF. (J Cardiovasc Electrophysiol, Vol. 14, pp. 609-615, June 2003) [source]


Irrigated-Tip Catheter Ablation of Pulmonary Veins for Treatment of Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 11 2002
LAURENT MACLE M.D.
Irrigated-Tip Catheter Ablation of PVs.Introduction: Catheter ablation of pulmonary veins (PV) for treatment of atrial fibrillation (AF) is limited by the disparate requirements of sufficient energy delivery to achieve PV isolation while avoiding PV stenosis. The aim of the present study was to evaluate the safety and efficacy of using an irrigated-tip catheter for systematic isolation of PV. Methods and Results: The study population consisted of 136 consecutive patients (109 men, mean age 52 ± 10 years) with symptomatic, drug-refractory paroxysmal (122) or persistent (14) AF. Cavotricuspid isthmus ablation and systematic radiofrequency isolation of all four PVs (guided by a circumferential mapping catheter) was performed in all patients with a protocol using an irrigated-tip catheter. PV diameter was assessed by selective angiography. The electrophysiologic endpoint of PV isolation was achieved in 100% of patients. Bidirectional cavotricuspid isthmus block was achieved in 99% of patients. Moderate PV stenosis (50% narrowing) was observed in one patient (0.7%) without clinical consequence. No other complications were observed. Reablation procedures were required in 67 patients (49%). After a mean follow-up of 8.8 ± 5.3 months, 81% of patients were free of AF clinical recurrence, including 66% not taking any antiarrhythmic drugs. Conclusion: Systematic radiofrequency ablation of PV using an irrigated-tip catheter in patients with atrial fibrillation allows complete isolation of all four PVs with a very low incidence of stenosis. [source]


Catheter Ablation for Paroxysmal Atrial Fibrillation: A Randomized Comparison between Multielectrode Catheter and Point-by-Point Ablation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2010
ALAN BULAVA M.D., Ph.D.
Introduction:,Catheter ablation for paroxysmal atrial fibrillation is widely used for patients with drug-refractory paroxysms of arrhythmia. Recently, novel technologies have been introduced to the market that aim to simplify and shorten the procedure. Aim:,To compare the clinical outcome of pulmonary vein (PV) isolation using a multipolar circular ablation catheter (PVAC group), with point-by-point PV isolation using an irrigated-tip ablation catheter and the CARTO mapping system (CARTO group; CARTO, Biosense Webster, Diamond Bar, CA, USA). Methods:,Patients with documented PAF were randomized to undergo PV isolation using PVAC or CARTO. Atrial fibrillation (AF) recurrences were documented by serial 7-day Holter monitoring. Results:,One hundred and two patients (mean age 58 ± 11 years, 68 men) were included in the study. The patients had comparable baseline clinical characteristics, including left atrial dimensions and left ventricular ejection fraction, in both study arms (PVAC: n = 51 and CARTO: n = 51). Total procedural and fluoroscopic times were significantly shorter in the PVAC group (107 ± 31 minutes vs 208 ± 46 minutes, P < 0.0001 and 16 ± 5 minutes vs 28 ± 8 minutes, P < 0.0001, respectively). The AF recurrence was documented in 23% and 29% of patients in the PVAC and CARTO groups, respectively (P = 0.8), during the mean follow-up of 200 ± 13 days. No serious complications were noted in both study groups. Conclusions:,Clinical success rates of PV isolation are similar when using multipolar circular PV ablation catheter and point-by-point ablation with a three-dimensional (3D) navigation system in patients with PAF, and results in shorter procedural and fluoroscopic times with a comparable safety profile. (PACE 2010; 33:1039,1046) [source]


Focal Ablation versus Single Vein Isolation for Atrial Tachycardia Originating from a Pulmonary Vein

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2010
BRYAN BARANOWSKI M.D.
Background: Rapid, disorganized firing from a pulmonary vein (PV) focus may initiate atrial fibrillation. The natural history of PV atrial tachycardia (AT), resulting in a slower, more organized form of firing, is less clear. Furthermore, the optimal therapeutic approach to a PV AT is poorly defined. Objective: This study assessed the characteristics and long-term outcomes of focal ablation versus PV isolation for ATs arising from a single PV. Methods: We reviewed 886 consecutive patients who underwent an AT radiofrequency ablation at our institution from January 1997 through August 2008. Results: Twenty-six patients had focal AT with a mean cycle length of 364 ± 90 ms that arose from within a single PV. Ten patients underwent focal ablation of their AT and 16 patients underwent PV isolation of the culprit vein. All procedures were acutely successful. The average follow-up was 25 months (range 2,90 months). There were three recurrences of AT in patients who underwent a focal ablation. There were no recurrences in patients who underwent targeted PV isolation (P = 0.046). No patients developed atrial fibrillation or AT from another focus during the follow-up period. Conclusion: PV AT can be successfully treated with single vein isolation or focal ablation with a low risk of recurrence or the development of atrial fibrillation. PV isolation may be the preferred approach when the AT focus arises from a site distal to the ostium where targeted ablation could result in phrenic nerve injury or occlusion of a pulmonary venous branch. (PACE 2010; 776,783) [source]


Usefulness of the Adenosine Triphosphate with a Sufficient Observation Period for Detecting Reconduction after Pulmonary Vein Isolation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 10 2009
YUICHI NINOMIYA M.D.
Background: Although reconduction after pulmonary vein (PV) isolation is considered to play a key role in the recurrence of paroxysmal atrial fibrillation (AF), there have been few reports regarding the precise time course of early reconduction. Several studies have suggested that transient PV reconduction facilitated by adenosine may predict long-term AF recurrence. This study was designed to clarify the incidence and time course of early reconduction after PVI during the procedure and to confirm whether the use of ATP after a certain observation period was useful to detect early reconduction after PVI. Methods: In 21 patients (18 males, 56 ± 11 years) with drug refractory AF, radiofrequency circumferential PV antrum ablation was performed in all 4 PVs. After the completion of isolation, electrograms in each PV were repeatedly recorded (1.98 ± 0.57 times per PV) using a circular mapping catheter for an observation period of 87 ± 29 minutes. After isolation of all 4 PVs, 30 mg of adenosine triphosphate (ATP) was administered during isoproterenol infusion. Results: PV electrical isolation was initially achieved in all 81 PVs. During the observation period, 12 (15%) PVs in 10 (48%) of 21 patients exhibited spontaneous reconduction. Among the remaining 69 PVs, 8 (12%) additional PVs had reconduction with the use of ATP. All PV reconduction was successfully eliminated by 4.5 ± 2.2 additional radiofrequency applications. Conclusion: A sufficient observation period and the use of ATP are useful to detect early reconduction after PV isolation. [source]


Steerable Sheath Catheter Navigation for Ablation of Atrial Fibrillation: A Case-Control Study

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2008
CHRISTOPHER PIORKOWSKI M.D.
Background: Lack of stable access to all desired ablation target sites is one of the limitations for efficacious circumferential left atrial (LA) pulmonary vein (PV) ablation. Targeting that, new catheter navigation technologies have been developed. The aim of this study was to describe atrial fibrillation (AF) mapping and ablation using manually controlled steerable sheath catheter navigation and to compare it against an ablation approach with a nonsteerable sheath. Methods and Results: In this case-control-analysis 245 consecutive patients (controls) treated with circumferential left atrial PV ablation were matched with 105 subsequently consecutive patients (cases) ablated with a similar line concept but mapping and ablation performed with a manually controlled steerable sheath. One hundred sixty-six patients were selected to be included into 83 matched patient pairs. Ablation success was measured with serial 7-day Holter electrocardiograms. Patients ablated with the steerable sheath showed an increase in the success rate (freedom from AF) from 56% to 77% (P = 0.009) after a single procedure and 6 months of follow-up. With respect to procedural data no difference could be found for procedure time, fluoroscopy time, irradiation dose, and radiofrequency (RF) burning time. With the steerable sheath mean procedural RF power (33 ± 9 vs 41 ± 4 W; P < 0.0005) and total RF energy delivery (97,498 vs 111,864 J; P < 0.005) were significantly lower and the rate of complete PV isolation significantly increased from 10% to 52% (P < 0.0005). The complication rate was the same in both groups. Among different arrhythmia, procedure, and patient characteristics, the lack of early postinterventional arrhythmia recurrences was the only but powerful predictor for long-term ablation success. Conclusions: An AF mapping and ablation approach solely using a manually controlled steerable sheath for catheter navigation improved the outcome of circumferential left atrial PV ablation at similar intervention times and similar complication rates. The 6-month success rate after a single LA intervention increased from 56% to 77%. [source]


Segmental Pulmonary Vein Ablation: Success Rates with and without Exclusion of Areas Adjacent to the Esophagus

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 6 2008
KLAUS KETTERING M.D.
Background: Catheter ablation has become the first line of therapy in patients with symptomatic recurrent, drug-refractory atrial fibrillation (AF). The occurrence of an atrioesophageal fistula is a rare but serious complication after AF-ablation procedures. This risk is even present during segmental pulmonary vein (PV) ablation procedures because the esophagus does frequently have a very close anatomical relationship to the right or left PV ostia. The aim of the present study was to analyze whether the exclusion of areas adjacent to the esophagus does have a significant effect on the success rates after segmental pulmonary vein ablation procedures. Methods: Forty-three consecutive patients with symptomatic paroxysmal AF were enrolled in this study. In all patients, a segmental PV ablation procedure was performed. The procedures were facilitated by a 3D real-time visualization of the circumferential mapping catheter placed in the pulmonary veins using the NavXÔ system (St. Jude Medical, St. Paul, MN, USA; open irrigated tip ablation catheter; 43°C; 30 W). In 21 patients, a complete ostial PV isolation was attempted regardless of the anatomical relationship between the ablation sites and the esophagus (group A). In the remaining 22 patients, the esophagus was marked by a stomach tube and areas adjacent to the esophagus were excluded from the ablation procedure (group B). After discharge, patients were scheduled for repeated visits at the arrhythmia clinic at 1, 3, and 6 months after the ablation procedure. Results: The segmental pulmonary vein ablation procedure could be performed as planned in all patients. In group A, all pulmonary veins could be isolated successfully in 14 out of 21 patients (67%). A mean number of 3.7 pulmonary veins (SD ± 0.5 PVs) were isolated per patient. The main reasons for an incomplete PV isolation were: small diameter of the PVs, side branches close to the ostium, or poorly accessible PV ostia. In group B, all PVs could be isolated successfully in only 12 out of 22 patients (55%; P = 0.54). A mean number of 3.2 PVs (SD ± 0.9 PVs) were isolated per patient (P = 0.05). This was mostly due to a close anatomical relationship to the esophagus. The ablation strategy had to be modified in 16/22 patients in group B because of a close anatomical relationship between the left (n = 10) or right (n = 6) PV ostia and the esophagus. After 3 months, the percentage of patients free from an AF recurrence was not significantly different between the two groups (90% vs 95%; P = 0.61). After 6 months, there was no significant difference between the success rates either (81% vs 82%; P = 1.0). There were no major complications in both groups. Conclusions: The exclusion of areas adjacent to the esophagus results in a moderately higher percentage of incompletely isolated PVs. However, it does not have a significant effect on the AF recurrence rate during short-term and mid-term follow-up. [source]


Pulmonary Vein Morphology Before and After Segmental Isolation in Patients with Atrial Fibrillation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2005
MAREHIKO UEDA
Background: The morphology of the pulmonary veins (PVs) before and after segmental isolation of the PVs has not been sufficiently characterized. Methods and Results: Multi-slice computed tomography was performed before and 3 ± 1 months after ablation in 30 patients with atrial fibrillation who underwent PV isolation. Before ablation, PV narrowing (,25% luminal reduction) was found in nine (8%) PVs. After ablation, de novo PV narrowing was found in 24 PVs (26%) and was detected only in the supero-inferior direction in 14 PVs (58%). The diameter reduction inside the PVs after ablation was greater in the supero-inferior direction (14 ± 12%) than in the antero-posterior direction (9 ± 13%; P < 0.0001). In the ablated PVs, the PV trunk was shorter than before ablation (P < 0.0001). The reduction in the diameters of both the PV ostium and the ablation site in the ablated PVs, as well as the diameter of the PV ostium in the nonablated PVs, correlated with the decrease in the left atrial diameter. Shortening of the PV trunk correlated with the severity of PV narrowing, but it was not related to the percent diameter reduction of the left atrium. PV narrowing before or after ablation did not result in any clinical consequences. Conclusions: PV narrowing is present in about 10% of PVs before ablation. Asymmetric luminal reduction and longitudinal shrinkage of the PV trunk occur after ablation. Reverse remodeling of the PV and contraction of the PV wall may contribute to the reduction in the PV diameter. PV morphology should be assessed with multi-directional views to avoid missing heterogeneous legions. [source]


Successful Pulmonary Vein Isolation Using Transvenous Catheter Cryoablation Improves Quality-of-Life in Patients with Atrial Fibrillation

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 5 2005
HUNG-FAT TSE
Background: Recent studies have demonstrated that transvenous catheter cryoablation is a safe and effective technique for creating pulmonary veins (PVs) electrical isolation for the treatment of atrial fibrillation (AF). However, the impacts of this procedure on quality-of-life (QoL) have not been evaluated. Methods and Results: We studied the effects of PV isolation using transvenous catheter cryoablation on QoL in 46 patients (34 men, mean age: 50 ± 12 years) with drug-refractory AF. QoL was assessed by Medical Outcomes Study Short Form-36 (SF-36) and Symptom Checklist at baseline and 3-month after cryoablation, and compared with those in a sex-age matched normal control. At 3-month follow-up, 24 of 46 patients (52%) had no recurrence of AF, including 11 patients who were not taking antiarrhythmic drugs. At baseline, patients with AF had significantly lower QoL scores in overall and in 5/8 subscales of SF-36 than the sex-age matched control group (P < 0.05). In patients with successful outcome after cryoablation showed a significant improvement in overall and in 5/8 subscales of SF-36 QoL scores have significantly increased as compared with the baseline (P < 0.05). Furthermore, their QoL scores in overall and in 6/8 subscales of SF-36 were similar to the sex-age matched control group (P > 0.05). The Symptom Checklist also showed significant reduction in both the symptoms frequency scores and symptoms severity scores at 3-month follow-up as compared with baseline (P < 0.05). Conclusions: Successful PV isolation using transvenous catheter cryoablation is associated with significant reduction in the frequency and severity of AF symptoms and improvement in the general QoL, reaching the levels of normal controls. [source]