Skip to main content
SpringerLink
Log in

Pulmonary venous isolation versus additional substrate modification as treatment for paroxysmal atrial fibrillation

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Background

Pulmonary vein isolation alone is ineffective in maintaining sinus rhythm in up to one third of patients with paroxysmal atrial fibrillation (AF). We compared pulmonary vein antral isolation plus additional limited ablation along the inferoposterior left atrium and epicardially within the adjacent coronary sinus (PVAI + CS) to pulmonary vein antral isolation (PVAI) alone in patients with paroxysmal AF.

Methods

Forty-two consecutive patients with paroxysmal AF were prospectively randomized to PVAI vs. PVAI + CS. All patients were seen 3, 6, 12, and 18 months after ablation and underwent 24-h ambulatory Holter monitoring.

Results

Following a single procedure, 17 out of 22 patients (77%) remained arrhythmia free off antiarrhythmic medication after PVAI at 18 months vs. 10 out of 20 (50%) after PVAI + CS (p < 0.01). After PVAI, three patients had recurrent paroxysmal AF, and two had atrial tachycardia, whereas after PVAI + CS, three patients had recurrent paroxysmal AF, and seven had atrial tachycardia. All patients in the PVAI + CS group with atrial tachycardia who underwent a second procedure were found to have peri-mitral macro-reentry as the underlying mechanism. Eighty-one percent of patients remained arrhythmia free off medication after 1.09 procedures in the PVAI group vs. 80% after 1.35 procedures in the PVAI + CS group (p < 0.01).

Conclusion

The addition of limited ablation along the inferoposterior left atrium and within the adjacent coronary sinus to PVAI alone did not reduce the recurrence rate of paroxysmal atrial fibrillation and was associated with an increased rate of peri-mitral macro-reentrant atrial tachycardia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Haïssaguerre, M., Jais, P., Shah, D. C., Takahashi, A., Hocini, M., Quiniou, G., et al. (1998). Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. The New England Journal of Medicine, 339, 659–666.

    Article  PubMed  Google Scholar 

  2. Haïssaguerre, M., Shah, D. C., Jaïs, P., Hocini, M., Yamane, T., Deisenhofer, I., et al. (2000). Electrophysiological breakthroughs from the left atrium to the pulmonary veins. Circulation, 102, 2463–2465.

    PubMed  Google Scholar 

  3. Haïssaguerre, M., Sanders, P., Hocini, M., Hsu, L. F., Shah, D. C., Scavée, C., et al. (2004). Changes in atrial fibrillation cycle length and inducibility during catheter ablation and their relation to outcome. Circulation, 109, 3007–3013.

    Article  PubMed  Google Scholar 

  4. Chen, S. A., Hsieh, M. W., Tai, C. T., Tsai, C. F., Prakash, V. S., Yu, W. C., et al. (1999). Initiation of atrial fibrillation by ectopic beats originating from pulmonary veins. Electrophysiological characteristics, pharmacological responses and effects of radiofrequency ablation. Circulation, 100, 1879–1886.

    PubMed  CAS  Google Scholar 

  5. Ouyang, F. F., Bänsh, D., Ernst, S., Schaumann, A., Hachiya, H., Chen, M., et al. (2004). Complete isolation of left atrium surrounding the pulmonary veins: new insights from the double-lasso technique in paroxysmal atrial fibrillation. Circulation, 110, 2090–2096.

    Article  PubMed  Google Scholar 

  6. Oral, H., Knight, B. P., Ozaydin, M., Chugh, A., Lai, S. W., Scharf, C., et al. (2002). Segmental ostial ablation to isolate the pulmonary veins during atrial fibrillation; feasibility and mechanistic insights. Circulation, 106, 1256–1262.

    Article  PubMed  Google Scholar 

  7. Cappato, R., Calkins, H., Chen, S. A., Davies, W., Iesaka, Y., Kalman, J., et al. (2010). Updated worldwide survey on the methods, efficacy and safety of catheter ablation for human atrial fibrillation. Circulation: Arrhythmia and Electrophysiology, 3, 32–38.

    Article  Google Scholar 

  8. Jaïs, P., Hocini, M., Hsu, L. F., Sanders, P., Scavee, C., Weerasooriya, R., et al. (2004). Technique and results of linear ablation at the mitral isthmus. Circulation, 110, 2996–3002.

    Article  PubMed  Google Scholar 

  9. Hocini, M., Jaïs, P., Sanders, P., Takahashi, Y., Rotter, M., Rostock, T., et al. (2005). Techniques, evaluation and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation-a prospective randomized study. Circulation, 112, 3688–3696.

    Article  PubMed  Google Scholar 

  10. Sanders, P., Hocini, M., Jaïs, P., Sacher, F., Hsu, L. F., Takahashi, Y., et al. (2007). Complete isolation of the pulmonary veins and posterior left atrium in chronic atrial fibrillation. Long-term clinical outcome. European Heart Journal, 28, 1862–1871.

    Article  PubMed  Google Scholar 

  11. Lim, T. W., Koay, C. H., McCall, R., See, V. A., Ross, D. L., & Thomas, S. P. (2008). Atrial arrhythmias after single-ring isolation of the posterior left atrium and pulmonary veins for atrial fibrillation: mechanisms and management. Circulation: Arrhythmia and Electrophysiology, 1, 120–126.

    Article  Google Scholar 

  12. Scanavacca, M., Pisani, C. F., Hachul, D., Lara, S., Hardy, C., Darrieux, F., et al. (2006). Selective atrial vagal denervation guided by evoked vagal reflex to treat patients with paroxysmal atrial fibrillation. Circulation, 114, 876–885.

    Article  PubMed  Google Scholar 

  13. Verma, A., Mantovan, R., Macle, L., De Martino, G., Chen, J., Morillo, C. A., et al. (2010). Substrate and trigger ablation for reduction of atrial fibrillation (STAR AF); a randomized, multicentre, international trial. European Heart Journal, 31, 1344–1356.

    Article  PubMed  Google Scholar 

  14. Kanj, M. H., Wazni, O. M., & Natale, A. (2006). How to do circular mapping catheter-guided pulmonary vein isolation: the Cleveland Clinic approach. Heart Rhythm, 3, 866–869.

    Article  PubMed  Google Scholar 

  15. Tamborero, D., Mont, L., Berruezo, A., Matiello, M., Benito, B., Sitges, M., et al. (2009). Left atrial posterior wall isolation does not improve the outcome of circumferential pulmonary vein ablation for atrial fibrillation: a prospective randomized study. Circulation: Arrhythmia and Electrophysiology, 2, 35–40.

    Article  Google Scholar 

  16. Kasai, A., Anselme, F., & Saoudi, N. (2001). Myocardial connections between left atrial myocardium and coronary sinus musculature in man. Journal of Cardiovascular Electophysiology, 12, 981–985.

    Article  CAS  Google Scholar 

  17. Volkmer, M., Antz, M., Hebe, J., & Kuck, K. H. (2002). Focal atrial tachycardia originating from the musculature of the coronary sinus. Journal of Cardiovascular Electrophysiology, 13, 68–71.

    Article  PubMed  Google Scholar 

  18. Navarrete, A. J., Arora, R., Hubbard, J. E., & Miller, J. M. (2003). Magnetic electroanatomic mapping of an atrial tachycardia requiring ablation within the coronary sinus. Journal of Cardiovascular Electrophysiology, 14, 1361–1364.

    Article  PubMed  Google Scholar 

  19. Olgin, J. E., Jayachandran, J. V., Engesstein, E., Groh, W., & Zipes, D. P. (1998). Atrial macroreentry involving the myocardium of the coronary sinus: a unique mechanism for atypical flutter. Journal of Cardiovascular Electrophysiology, 9, 1094–1099.

    Article  PubMed  CAS  Google Scholar 

  20. Teh, A. W., Kalman, J. M., Kistler, P. M., Lee, G., Sutherland, F., Morton, J. B., et al. (2010). Prevalence of fractionated electrograms in the coronary sinus: comparison between patients with persistent or paroxysmal atrial fibrillation and a control population. Heart Rhythm, 7, 1200–1204.

    Article  PubMed  Google Scholar 

  21. Oral, H., Ozaydin, M., Chugh, A., Scharf, C., Tada, H., Hall, B., et al. (2003). Role of the coronary sinus in maintenance of atrial fibrillation. Journal of Cardiovascular Electrophysiology, 14, 1329–1336.

    Article  PubMed  Google Scholar 

  22. Rotter, M., Sanders, P., Takahashi, Y., Hsu, L. F., Sacher, F., Hocini, M., et al. (2004). Images in cardiovascular medicine. Coronary sinus tachycardia driving atrial fibrillation. Circulation, 110, e59–e60.

    Article  PubMed  Google Scholar 

  23. Haïssaguerre, M., Hocini, M., Takahashi, Y., O’Neill, M. D., Pernat, A., Sanders, P., et al. (2007). Impact of catheter ablation of the coronary sinus on paroxysmal or persistent atrial fibrillation. Journal of Cardiovascular Electrophysiology, 18, 378–386.

    Article  PubMed  Google Scholar 

  24. Fuster, V., Rydén, L. E., Cannom, D. S., Crijins, H. J., Curtis, A. B., Ellenbogen, K. A., et al. (2006). ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Journal of the American College of Cardiology, 48, E149.

    Article  Google Scholar 

  25. Verma, A., Novak, P., Macle, L., Whaley, B., Beardsall, M., Wulffhart, Z., et al. (2008). A prospective, multicenter evaluation of ablating complex fractionated electrograms (CFEs) during atrial fibrillation (AF) identified by an automated mapping algorithm: acute effects on AF and efficacy as an adjuvant strategy. Heart Rhythm, 5, 198–205.

    Article  PubMed  Google Scholar 

  26. Stiles, M. K., John, B., Wong, C. X., Kuklik, P., Brooks, A. G., Lau, D. H., et al. (2009). Paroxysmal lone atrial fibrillation is associated with an abnormal atrial substrate characterizing the ‘second factor’. Journal of the American College of Cardiology, 53, 1182–1191.

    Article  PubMed  Google Scholar 

  27. Takahashi, Y., O’Neill, M., Hocini, M., Reant, P., Jonsson, A., Jaïs, P., et al. (2007). Effects of stepwise ablation of chronic atrial fibrillation on atrial electrical and mechanical properties. Journal of the American College of Cardiology, 49, 1306–1314.

    Article  PubMed  Google Scholar 

  28. Shah, A., Jadidi, A., Liu, X., Miyazaki, S., Forclaz, A., Nault, I., et al. (2010). Atrial tachycardias arising from ablation of atrial fibrillation: a proarrhythmic bump or antiarrhythmic turn? Cardiology Research and Practise, 1, 1–9.

    Article  Google Scholar 

  29. Gerstenfeld, E., Callans, D., Dixit, S., Russo, A. M., Nayak, H., Lin, D., et al. (2004). Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation. Circulation, 110, 1351–1357.

    Article  PubMed  Google Scholar 

  30. Essebag, V., Wylie, J. V., Reynolds, M. R., Baldessin, F., McClennen, S., Shvilkin, A., et al. (2006). Bi-directional electrical pulmonary isolation as an endpoint for ablation of paroxysmal atrial fibrillation. Journal of Interventional Cardiac Electrophysiology, 17, 111–117.

    Article  PubMed  Google Scholar 

  31. Karch, M., Zrenner, B., Deisenhofer, I., Schreieck, J., Ndrepepa, G., Dong, J. L., et al. (2005). Freedom from atrial tachyarrhythmia after catheter ablation of atrial fibrillation: a randomized comparison between 2 current ablation strategies. Circulation, 111, 2875–2880.

    Article  PubMed  Google Scholar 

  32. Shah, D., Sunthorn, H., Burri, H., Gentil-Baron, P., Pruvot, E., Schlaepfer, J., et al. (2006). Narrow, slow conducting isthmus dependent left atrial reentry developing after ablation of atrail fibrillation: ECG characterization and elimination by focal RF ablation. Journal of Cardiovascular Electrophysiology, 17, 508–515.

    Article  PubMed  Google Scholar 

  33. Cummings, J., Schweikert, R., Saliba, W., Hao, S., Martin, D. O., Marrouche, N. F., et al. (2005). Left atrial flutter following pulmonary vein antrum isolation with radiofrequency energy: linear lesions or repeat isolation. Journal of Cardiovascular Electrophysiology, 16, 293–297.

    Article  PubMed  Google Scholar 

  34. Deisenhofer, I., Estner, H., Zrenner, B., Schreieck, J., Weyerbrock, S., Hessling, G., et al. (2006). Left atrial tachycardia after circumferential pulmonary vein ablation for atrial fibrillation: incidence, electrophysiological characteristics and results of radiofrequency ablation. Europace, 8, 573–582.

    Article  PubMed  Google Scholar 

  35. Daoud, E., Weiss, R., Augostini, R., Hummel, J. D., Kalbfleisch, S. J., Van Deren, J. M., et al. (2006). Proarrhythmia of circumferential left atrial lesions for management of atrial fibrillation. Journal of Cardiovascular Electrophysiology, 17, 157–165.

    Article  PubMed  Google Scholar 

  36. Mesas, C., Pappone, C., Lang, C. C., Gugliotta, F., Tomita, T., Vicedomini, G., et al. (2004). Left atrial tachycardia after circumferential pulmonary vein ablation of atrial fibrillation: electroanatomic characterization and treatment. Journal of the American College of Cardiology, 44, 1071–1079.

    Article  PubMed  Google Scholar 

  37. Chae, S., Oral, H., Good, E., Dey, S., Wimmer, A., Crawford, T., et al. (2007). Atrial tachycardia after circumferential pulmonary vein ablation of atrial fibrillation. Mechanistic insights, results of catheter ablation and risk factors for recurrence. Journal of the American College of Cardiology, 50, 1781–1787.

    Article  PubMed  Google Scholar 

  38. Morady, F., Oral, H., & Chugh, A. (2009). Diagnosis and ablation of atypical atrial tachycardia and flutter complicating atrial fibrillation ablation. Heart Rhythm, 6(8 Suppl), S29–S32.

    Article  PubMed  Google Scholar 

  39. Jaïs, P., Matsuo, S., Knecht, S., Weerasooriya, R., Hocini, M., Sacher, F., et al. (2009). A deductive mapping strategy for atrial tachycardia following atrial fibrillation ablation: importance of localized reentry. Journal of Cardiovascular Electrophysiology, 20, 480–491.

    Article  PubMed  Google Scholar 

  40. Di Biase, L., Elayi, C. S., Fahmy, T. S., Martin, D. O., Ching, C. K., Barrett, C., et al. (2009). Atrial fibrillation strategies for paroxysmal patients: randomized comparison between different techniques. Circulation: Arrhythmia and Electrophysiology, 2, 113–119.

    Article  Google Scholar 

  41. Lemola, K., Oral, H., Chugh, A., Hall, B., Cheung, P., Han, J., et al. (2005). Pulmonary vein isolation as an end-point for left atrial circumferential ablation of atrial fibrillation. Journal of the American College of Cardiology, 46, 1060–1066.

    Article  PubMed  Google Scholar 

  42. Arentz, T., Weber, R., Bürkle, G., Herrera, C., Blum, T., Stockinger, J., et al. (2005). Small or large isolation areas around the pulmonary veins for the treatment of atrial fibrillation? Results from a prospective randomized study. Circulation, 115, 3057–3063.

    Article  Google Scholar 

  43. Caló, L., Lamberti, F., Loricchio, M. L., De Ruvo, E., Colivicchi, F., Bianconi, L., et al. (2006). Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. Journal of the American College of Cardiology, 47, 2504–2512.

    Article  PubMed  Google Scholar 

  44. Udyavar, A. R., Chang, S. L., Tai, C. T., Lin, Y. J., Lo, L. W., Tuan, T. C., et al. (2008). The important role of pulmonary vein carina ablation as an adjunct to circumferential pulmonary vein isolation. Journal of Cardiovascular Electrophysiology, 19, 593–598.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia, 5042, Australia

    Andrew Robertson Gavin, Cameron B. Singleton, John Bowyer & Andrew D. McGavigan

  2. Faculty of Medicine, Flinders University, Adelaide, South Australia, 5042, Australia

    Andrew D. McGavigan

Authors
  1. Andrew Robertson Gavin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Cameron B. Singleton
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John Bowyer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andrew D. McGavigan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andrew D. McGavigan.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gavin, A.R., Singleton, C.B., Bowyer, J. et al. Pulmonary venous isolation versus additional substrate modification as treatment for paroxysmal atrial fibrillation. J Interv Card Electrophysiol 33, 101–107 (2012). https://doi.org/10.1007/s10840-011-9614-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-011-9614-9

Keywords

Search

Navigation