Pulmonary vein isolation: The impact of pulmonary venous anatomy on long-term outcome of catheter ablation for paroxysmal atrial fibrillation☆,☆☆
Introduction
Circumferential pulmonary antral ablation is a commonly used technique to achieve pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). However, PVI is limited by AF recurrence in up to 30% of the patients with paroxysmal AF.1 Despite advances in catheter-based technology and operator experience, pulmonary vein (PV) reconnection continues to thwart the success of catheter ablation.
Pulmonary venous anatomy demonstrates considerable inter- and intraindividual variation with common PVs, accessory PVs, and significant difference in the dimensions of the intervenous ridge and PV-appendage ridge. With advances in catheter contact technology, we have gained new insights into the challenges of tissue contact at these locations that may in part translate to the variable outcomes after PVI. The intervenous ridge (IVR) and the left PV-left atrial appendage (LAA) ridge are preferential sites of not only acute PV isolation but also chronic PV reconnection.2, 3 Interestingly, adequate catheter contact is difficult to achieve in these locations4, 5 and may translate to sites of PV reconnection at the time of repeat procedure for recurrent AF.4
Prior studies have explored the impact of pulmonary venous anatomy on the outcomes of catheter ablation with conflicting results. Pulmonary venous anatomy demonstrates considerable diversity with a left common pulmonary vein (LCPV) present in 9%–83% of the patients and accessory PVs in 17%–29% of the patients undergoing catheter ablation.6, 7 Right-sided accessory PVs have been associated with improved success after PVI,8 though other series did not demonstrate an association between atrial anatomy and procedural outcomes.9, 10
We conducted a prospective study to determine the impact of pulmonary venous anatomy on outcome after catheter ablation for paroxysmal AF.
Section snippets
Study population
Patients with highly symptomatic paroxysmal AF resistant to at least 1 antiarrhythmic drug (AAD) were prospectively recruited before first time PVI between January 2010 and January 2012. Patients underwent preprocedural cardiac magnetic resonance (CMR) imaging or computed tomography (CT) for the assessment of LA anatomy. AF was classified as paroxysmal if episodes were self-terminating within 7 days or cardioverted within 48 hours of onset. Patients were required to have normal renal function
Baseline characteristics and procedural outcomes
One hundred two patients with paroxysmal AF (mean age 59 ± 9 years; 67% men) underwent CMR or CT before AF ablation (MRI in 60% and CT in 40%). Segmentation of the left atriogram for LA anatomy was performed with NavX in 85% and with CARTO 3 in 15%. Acute procedural success, defined as PVI, was achieved in all patients. At a mean follow-up of 12 ± 4 months, 75 of 102 (74%) patients were in sinus rhythm off AAD after a single procedure (Table 1).
Common or accessory PVs
Four discrete PVs were identified in 47% of the
Discussion
Atrial and PV anatomy demonstrates considerable variation between patients. 3D mapping with image integration has improved our appreciation of the anatomic diversity and assisted our ability to complete PVI despite often challenging terrain. In the present study, we demonstrated that pulmonary venous anatomy is an important determinant of outcome in patients undergoing PVI for paroxysmal AF. The main findings were as follows:
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typical 4-PV anatomy is present in 47% of the patients, with a LCPV in
Conclusions
Four discrete PVs are present in the minority of patients with paroxysmal AF undergoing PVI. The presence of a LCPV is associated with an increased freedom from AF after catheter ablation. PV anatomy may in part explain the variable outcome to electrical isolation in patients with paroxysmal AF.
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Left atrial, pulmonary vein, and left atrial appendage anatomy in Indigenous individuals: Implications for atrial fibrillation
2021, IJC Heart and VasculatureCitation Excerpt :We also determined measurements of the PVs and LAA in Indigenous Australians. The PVs are a crucial source of AF triggers, and differences in PV anatomy have been recognised to affect the susceptibility to and recurrence of AF [25–27]. With the exception of superioinferior diameters in the left inferior PVs, which was no longer significant after correction for multiple testing (p = 0.13), we could again not demonstrate any consistent differences in PV number, morphology, diameters, or ostial characteristics.
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2020, Archives of Cardiovascular DiseasesCitation Excerpt :This configuration is observed in 57–82% of the population [7,11–16]. Anatomical variants of this typical drainage have been described in 18–53% of patients [11,13,16–18], the most common being the presence of a left common trunk (8–59%) [3,4,6,7,16–19]. Anatomical variants of the right PVs are less common (6–32%) [7,11,12,14,16–18], but tend to be more complex because of the presence of a third PV coming from the middle pulmonary lobe, draining either into the superior or inferior PV, or directly into the LA through a separated ostium.
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This research was supported in part by the Victorian Government’s Operational Infrastructure Funding.
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Dr McLellan is supported by a co-funded Australian National Health and Medical Research Council (NHMRC)/Australian National Heart Foundation (NHF) Postgraduate Scholarship. Dr Ling is supported by an NHF Postgraduate Scholarship. Dr Wong is the recipient of the Keith Goldsbury Postgraduate Research Scholarship Award (award no. PC11M 6218) from the National Heart Foundation of Australia. Dr Walters is supported by an NHMRC Postgraduate Research Scholarship. Dr Taylor is supported by an NHMRC project grant. Dr Kistler is supported by a practitioner fellowship from the NHMRC.