A new interpretation of nonpulmonary vein substrates of the left atrium in patients with atrial fibrillation

Rillo, Mariano; Palamà, Zefferino; Punzi, Raffaele; Vitanza, Salvatore; Aloisio, Angelo; Polini, Silvia; Tucci, A.; Pollastrelli, Annalisa; Zonno, Francesco; Anastasia, Antonio; Giannattasio, Cesare; My, Luigi

doi:10.1002/joa3.12521

Cited by 7 publications

(6 citation statements)

References 29 publications

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“…We previously reported that ablation outcome in AF patients with non-PV triggers could be improved to the level of those without non-PV triggers, by selective mapping and ablation of non-PV triggers [ 15 ]. For detailed mapping, it is also important to evaluate the substrate such as fibrosis by using multipolar electrodes [ 22 ]. Therefore, a standardized mapping strategy for non-PV trigger mapping has been awaited.…”

Section: Discussionmentioning

confidence: 99%

Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation

et al. 2022

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Background Pulmonary vein isolation (PVI) is an established ablation procedure for atrial fibrillation (AF), however, PVI alone is insufficient to suppress AF recurrence. Non-pulmonary vein (non-PV) trigger ablation is one of the promising strategies beyond PVI and has been shown to be effective in refractory/persistent AF cases. To make non-PV trigger ablation more standardized, it is essential to develop a simple method to localize the origin of non-PV triggers. Methods We retrospectively analyzed 37 non-PV triggers in 751 ablation sessions for symptomatic AF from January 2017 to December 2020. Regarding non-PV triggers, intra-atrial activation interval from the earliest in right atrium (RA) to proximal coronary sinus (CS) (RA-CSp) and that from the earliest in RA to distal CS (RA-CSd) obtained by a basically-positioned duodecapolar RA-CS catheter were compared among 3 originating non-PV areas [RA, atrial septum (SEP) and left atrium (LA)]. Results RA-CSp of RA non-PV trigger (56.4 ± 23.4 ms) was significantly longer than that of SEP non-PV (14.8 ± 25.6 ms, p = 0.019) and LA non-PV (-24.9 ± 27.9 ms, p = 0.0004). RA-CSd of RA non-PV (75.9 ± 32.1 ms) was significantly longer than that of SEP non-PV (34.2 ± 32.6 ms, p = 0.040) and LA non-PV (-13.3 ± 41.2 ms, p = 0.0008). RA-CSp and RA-CSd of SEP non-PV were significantly longer than those of LA non-PV (p = 0.022 and p = 0.016, respectively). Sensitivity and specificity of an algorithm to differentiate the area of non-PV trigger using RA-CSp (cut-off value: 50 ms) and RA-CSd (cut-off value: 0 ms) were 88% and 97% for RA non-PV, 81% and 73% for SEP non-PV, 65% and 95% for LA non-PV, respectively. Conclusions The analysis of intra-atrial activation sequences was useful to differentiate non-PV trigger areas. A simple algorithm to localize the area of non-PV trigger would be helpful to identify non-PV trigger sites in AF ablation.

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Section: Discussionmentioning

confidence: 99%

Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation

et al. 2022

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“…is allows us to see with different eyes, with a magnifying glass, what we could not see in the past years. Left atrial substrate modification by targeting lowvoltage zones is an ablation strategy that, in addition to PVI, tries to erase arrhythmogenic mechanisms harbored in such tissue [34,[36][37][38]. e common feeling is that PVI alone is not sufficient; therefore, some of the new techniques could allow us to better target a tailor-made ablative treatment, adapting the ablation to the characteristics of the different patients and their substrates.…”

Section: Persistent Afmentioning

confidence: 99%

Tailoring the Ablative Strategy for Atrial Fibrillation: A State-of-the-Art Review

Palamà

Nesti

Robles

et al. 2022

Cardiology Research and Practice

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In spite of technological progress and the improving skills of operators, atrial fibrillation (AF) ablation results appear to date to be at a plateau. In any case, the superiority of ablation over pharmacological therapy in terms of effectiveness, reduction of hospitalizations, and improvement has been well demonstrated in recent randomized trials. Triggers, substrate, and modulating factors (elements of Coumel’s triangle) play different roles in paroxysmal and persistent AF, so induction and perpetuation mechanisms of arrhythmia may be different in each patient. Although effective ablative strategies are available for the treatment of paroxysmal AF triggers and persistent AF substrates, an adequate clinical evaluation of the patient is crucial in order to increase the chances of success. Recognizing triggers allows not only performing an effective ablation but also to avoid unnecessary lesions and at the same time reducing the risk of complications. AF beginning and triggers could be recorded by 12-lead ECG, continuous Holter monitoring, or implantable devices. In case of an unsuccessful noninvasive evaluation, nonpulmonary vein triggers should be investigated with an electrophysiological study. Persistent AF needs more effort to perform an accurate substrate characterization. Among the many methods proposed, recently the use of high-density mapping and multipolar catheters seems of particular benefit in order to clarify the arrhythmia mechanisms. Surgical and hybrid techniques allow to treat regions such as the posterior wall or Bachmann’s bundle, which is fundamental for an ablative strategy that goes beyond just pulmonary vein isolation. Too often, patients are referred to electrophysiology laboratories without adequate preprocedural screening and planning in order to submit them to a standard “ready-made” procedure. The accurate search for triggers in paroxysmal AF and the correct recognition of the link between a possible underlying heart disease and the substrate in persistent AF could allow us to tailor the interventional approach in order to overcome the current plateau, increasing ablative procedure success and minimizing complications.

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“…However, to avoid any misleading interpretation of the underlying circuit, accurate and high-density mapping of investigated atrial chambers is required to account for almost 90% of the tachycardia cycle length and thereby avoiding missing mapping segments potentially due to non-annotated low-amplitude and fragmented electrograms as low as 0.03–0.05 mV [ 27 ]. In this setting, the recent development of new tools, such as Octaray TM system (Biosense Webster Inc., Irvine, CA, USA) and the Ensite TM Omnipolar Technology (OT) (Abbott, Chicago, IL, USA) might allow for even better results [ 62 , 63 , 64 ], provided that the multitude of signals collected is correctly acquired and interpreted.…”

Section: The Winding Path To Improve the Procedures And The Overall C...mentioning

confidence: 99%

Procedural Feasibility and Long-Term Efficacy of Catheter Ablation of Atypical Atrial Flutters in a Wide Spectrum of Heart Diseases: An Updated Clinical Overview

Ponti

Marazzi²,

Vilotta³

et al. 2022

JCM

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Atypical atrial flutters (AAFL) are difficult-to-manage atrial arrhythmias, yet potentially amenable to effective radiofrequency catheter ablation (CA). However, data on CA feasibility are only sparingly reported in the literature in different clinical settings, such as AAFL related to surgical correction of congenital heart disease. The aim of this review was to provide an overview of the clinical settings in which AAFL may occur to help the cardiac electrophysiologist in the prediction of the tachycardia circuit location before CA. Moreover, the role and proper implementation of cutting-edge technologies in this setting were investigated as well as which procedural and clinical factors are associated with long-term failure to maintain sinus rhythm (SR) to find out which patients may, or may not, benefit from this procedure. Not only different surgical and non-surgical scenarios are associated with peculiar anatomical location of AAFL, but we also found that CA of AAFL is generally feasible. The success rate may be as low as 50% in surgically corrected congenital heart disease (CHD) patients but up to about 90% on average after pulmonary vein isolation (PVI) or in patients without structural heart disease. Over the years, the progressive implementation of three-dimensional mapping systems and high-density mapping tools has also proved helpful for ablation of these macro-reentrant circuits. However, the long-term maintenance of SR may still be suboptimal due to the progressive electroanatomic atrial remodeling occurring after cardiac surgery or other interventional procedures, thus limiting the likelihood of successful ablation in specific clinical settings.

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A new interpretation of nonpulmonary vein substrates of the left atrium in patients with atrial fibrillation

Cited by 7 publications

References 29 publications

Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation

Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation

Tailoring the Ablative Strategy for Atrial Fibrillation: A State-of-the-Art Review

Procedural Feasibility and Long-Term Efficacy of Catheter Ablation of Atypical Atrial Flutters in a Wide Spectrum of Heart Diseases: An Updated Clinical Overview

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