Original-clinicalSingle procedure efficacy of isolating all versus arrhythmogenic pulmonary veins on long-term control of atrial fibrillation: A prospective randomized study
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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2016, JACC: Clinical ElectrophysiologyCitation Excerpt :Supporting this hypothesis is the pivotal study by Haissaguerre et al. (3), in which ablation targeted ectopic foci often in only 1 to 2 PVs, and 62% of patients were AF-free over a follow-up period of 8 ± 6 months. Dixit et al. (24) compared electrical isolation of only arrhythmogenic PVs with empiric isolation of all PVs in a randomized study evaluating 105 patients. The primary endpoint (freedom or >90% reduction in AF burden while receiving previously ineffective antiarrhythmic drugs, or not, at 1 year after a single ablation procedure) was achieved in 75% of patients randomized to all-PV arm versus 71% in the arrhythmogenic PV arm (odds ratio: 1.18; 95% CI: 0.50 to 2.83; p = 0.70).
Prevalence and distribution of focal triggers in persistent and long-standing persistent atrial fibrillation
2016, Heart RhythmCitation Excerpt :At the beginning of the procedure, programmed atrial stimulation was performed to exclude the presence of triggers approachable from the right atrium, such as atrioventricular nodal reentrant tachycardia (AVNRT) or right atrial tachycardias. The presence of PV and non-PV triggers was elicited with the following protocol12,13: (1) isoproterenol infusion (starting at 3 μg and incrementing every 3–5 minutes to 6, 12, and 20 μg) and (2) cardioversion of spontaneous AF or AF induced by left or right atrial pacing (15-beat drive train at an amplitude of 10 mA and a pulse width of 2 ms; decrementing from 250 to 180 ms in steps of 10 ms with 5-second pause between drive trains and/or failure to capture the atrial tissue 1:1 with 5-second pause between drive trains); the latter was performed with the specific aim of identifying postcardioversion AF triggers. As part of the trigger protocol, multiple cardioversions were typically necessary whenever AF was induced (either spontaneously or with isoproterenol infusion/burst pacing) with the end point of mapping the trigger beat(s), leading to postcardioversion early AF recurrence.
This study was supported by an unrestricted grant from Boston Scientific.
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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.