Elsevier

Heart Rhythm

Volume 5, Issue 2, February 2008, Pages 174-181
Heart Rhythm

Original-clinical
Single procedure efficacy of isolating all versus arrhythmogenic pulmonary veins on long-term control of atrial fibrillation: A prospective randomized study

https://doi.org/10.1016/j.hrthm.2007.09.024Get rights and content

Background

Current atrial fibrillation (AF) ablation involves isolation of all pulmonary veins (PVs) with or without additional linear lesions. However, whether such extensive ablation is necessary is unclear.

Objective

The purpose of this study was to assess the efficacy of different ablation strategies on long-term AF control.

Methods

We prospectively randomized patients to undergo isolation of all versus arrhythmogenic PVs (identified by standardized stimulation protocol). PV isolation was guided by circular mapping catheter. The endpoint was entry/exit block persisting for ≥20 minutes. Patients were evaluated at three clinic visits (at 6 weeks, 6 months, and 1 year) and multiple transtelephonic monitoring periods. Antiarrhythmic drugs were discontinued at 6 weeks. Primary study endpoint was long-term AF control (freedom or >90% reduction in AF burden off or on previously ineffective antiarrhythmic drugs at 1year after a single ablation procedure).

Results

Over a 20-month period, 105 patients (76 men and 29 women, age 57 ± 9 years; paroxysmal AF = 77) were randomized, and 103 patients completed 1-year follow-up (51 patients in all-PV arm, 52 patients in arrhythmogenic PV arm). The primary endpoint was achieved in 75 (73%) patients and was similar in patients randomized to all-PV arm versus arrhythmogenic PV arm [38 (75%) patients vs 37 (71%) patients, respectively; odds ratio 1.18, 95% confidence interval 0.50, 2.83, P = .70]. Secondary study endpoints, including freedom from AF off antiarrhythmic drugs, total procedure/fluoroscopy times, and occurrence of serious adverse events, were not different between the two groups.

Conclusion

In a randomized comparison, isolation of arrhythmogenic veins was as efficacious as empiric isolation of all veins in achieving long-term AF control.

Introduction

Since its original description in 1998,1 the atrial fibrillation (AF) ablation procedure has undergone several modifications. Many operators performing AF ablation use an anatomic approach that involves creation of circumferential radiofrequency (RF) ablation lesions encircling ipsilateral pulmonary veins (PVs) with or without additional left atrial (LA) linear lesions.2, 3, 4 Practitioners of this approach do not seek proof of PV “arrhythmogenicity” and may not consistently document isolation of the targeted veins. Although this strategy has shown good AF control rates, it involves extensive LA ablation.2, 3 An alternative approach is to target only the arrhythmogenic PVs.5 This technique has not gained wide acceptance because PV triggers of AF can be evanescent, and no established protocol has been consistently shown to reproducibly elicit them.6 The advantage of this approach may be the ability to achieve AF control by limiting ablations to only the arrhythmogenic veins. The purpose of this study was (1) to evaluate in a prospective and randomized design the ability of our stimulation protocol to identify arrhythmogenic PVs and (2) to compare the efficacy of isolating thus identified arrhythmogenic PVs versus empiric isolation of all PVs on long-term control of AF. We hypothesized that isolation of all PVs would be more efficacious than isolation of arrhythmogenic veins only in achieving long-term AF control.

Section snippets

Study design

This was a single-center study in which participating subjects were blinded to intended treatment group prior to the procedure and were randomized (using a 2 × 2 factorial table) to undergo isolation of all versus arrhythmogenic PVs using either a 4-mm-tip (NaviStar, Biosense Webster, Diamond Bar, CA, USA), 8-mm-tip (NaviStar, Biosense Webster), or cooled tip (Chilli, Boston Scientific, Natick, MA, USA) catheter. Randomization sequence and subject recruitment over the course of the study period

Results

Over a 20-month period (July 2003 to February 2005), 106 (42%) of 251 eligible subjects were enrolled in the study. Fifty-three subjects were randomized to the all-vein arm, 52 subjects were randomized to the arrhythmogenic vein arm, and 1 subject was excluded after being randomized (see below). The average age of the population was 57 ± 9 years (76 men and 29 women), and the majority of patients (n = 77 [73%]) had paroxysmal AF. There was no significant difference in the demographic profile of

Discussion

In this single-center, randomized study comparing the efficacy of isolating all versus arrhythmogenic veins on long-term control of AF after a single ablation procedure, the following observations were made. (1) Our stimulation protocol successfully identified arrhythmogenic PVs in a mixed population of patients undergoing AF ablation. (2) Isolation of arrhythmogenic PVs was as efficacious as empiric isolation of all veins in achieving long-term AF control. (3) There was no significant

Conclusion

In a mixed population of patients with predominantly paroxysmal AF, isolation of arrhythmogenic veins identified using a comprehensive stimulation protocol was as efficacious as empiric isolation of all veins in achieving long-term arrhythmia control after a single ablation procedure.

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    This study was supported by an unrestricted grant from Boston Scientific.

    1

    Dr. Dixit is supported by an American College of Cardiology Foundation-Proctor Gamble Career Development Award in Cardiac Arrhythmias and The McCabe Pilot Fund Award.

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