Ablation for longstanding permanent atrial fibrillation: Results from a randomized study comparing three different strategies

Elayi, Claude S.; Verma, Atul; Biase, Luigi Di; Ching, Chi Keong; Patel, Dimpi; Barrett, Conor D.; Martin, David O.; Bai, Rong; Fahmy, Tamer S.; Khaykin, Yaariv; Hongo, Richard; Sheng, Hao; Pelargonio, Gemma; Russo, Antonio Dello; Casella, Michela; Santarelli, P; Potenza, Domenico; Fanelli, Raffaele; Massaro, Rosalba; Arruda, Maurício; Schweikert, Robert A.; Natale, Andrea

doi:10.1016/j.hrthm.2008.09.016

Cited by 263 publications

(232 citation statements)

References 21 publications

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“…Ablation of CFAEs for the treatment of AF was introduced by Nademanee et al 14 In 3 randomized trials, predominantly with smaller patient cohorts, ablation of CFAEs in addition to PVI demonstrated lower rates of recurrence of atrial tachyarrhythmias than stand-alone PVI. 5,8,10 Furthermore, additional linear ablation demonstrated better clinical outcomes in another 3 randomized trials. 6,7,12 Nonetheless, results of other trials did not show a clinical benefit of additional CFAE ablation, 4,9 and the recently published STAR AF II trial revealed no difference in clinical outcomes when comparing stand-alone PVI to PVI plus additional CFAE or linear ablation in a large cohort of patients with persistent AF.…”

Section: Current Ablation Strategies For Chronic Afmentioning

confidence: 94%

“…3 The optimal strategy for persistent AF is not known, and previous studies investigating more extensive ablation strategies in addition to PVI demonstrated heterogeneous results. [4][5][6][7][8][9][10][11][12] The recently published STAR AF 2 trial (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial) compared initial stand-alone PVI to PVI with additional ablation of complex fractionated atrial electrograms (CFAEs) or additional linear ablation and could not demonstrate a superior outcome for the additional ablation strategies. 13 The prospective and randomized Alster-Lost-AF © 2017 American Heart Association, Inc.…”

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confidence: 99%

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Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Fink

Schlüter

Heeger

et al. 2017

Circ: Arrhythmia and Electrophysiology

150

105

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C atheter ablation has become a routine treatment option for patients experiencing symptomatic paroxysmal atrial fibrillation (AF). Long-term clinical success rates of ≤80% after 5 years have been reported for the treatment of paroxysmal AF by initial stand-alone pulmonary vein isolation (PVI) as the accepted cornerstone of all AF ablation strategies; however, to achieve permanent PVI, multiple procedures are often required. 1,2 In contrast, the results for ablation of persistent AF are less convincing. 3 The optimal strategy for persistent AF is not known, and previous studies investigating more extensive ablation strategies in addition to PVI demonstrated heterogeneous results. [4][5][6][7][8][9][10][11][12] The recently published STAR AF 2 trial (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial) compared initial stand-alone PVI to PVI with additional ablation of complex fractionated atrial electrograms (CFAEs) or additional linear ablation and could not demonstrate a superior outcome for the additional ablation strategies. 13 The prospective and randomized Alster-Lost-AF © 2017 American Heart Association, Inc. Original ArticleBackground-Pulmonary vein isolation (PVI) for persistent atrial fibrillation is associated with limited success rates and often requires multiple procedures to maintain stable sinus rhythm. In the prospective and randomized Alster-Lost-AF trial (Ablation at St. Georg Hospital for Long-Standing Persistent Atrial Fibrillation), we sought to assess, in patients with symptomatic persistent or long-standing persistent atrial fibrillation, the outcomes of initial ablative strategies comprising either stand-alone PVI (PVI-only approach) or a stepwise approach of PVI followed by complex fractionated atrial electrogram ablation and linear ablation (Substrate-modification approach). Methods and Results-Patients were randomized 1:1 to stand-alone PVI or PVI plus substrate modification. The primary study end point was freedom from recurrence of any atrial tachyarrhythmia, outside a 90-day blanking period, at 12 months. A total of 124 patients were enrolled, with 118 patients included in the analysis (61 in the PVI-only group, 57 in the Substrate-modification group). Atrial tachyarrhythmias recurred in 28 PVI-only group patients and 24 Substratemodification group patients, for 1-year freedom from tachyarrhythmia recurrence after a single ablation procedure of 54% (95% confidence interval, 43%-68%) in the PVI-only and 57% (95% confidence interval, 46%-72%) in the Substratemodification group (P=0.86). Twenty-four patients in the PVI-only group (39%) and 18 in the Substrate-modification group (32%) were without arrhythmia recurrence and off antiarrhythmic drug therapy at the end of the 12-month follow-up. Conclusions-In

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Section: Current Ablation Strategies For Chronic Afmentioning

confidence: 94%

mentioning

confidence: 99%

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Fink

Schlüter

Heeger

et al. 2017

Circ: Arrhythmia and Electrophysiology

150

105

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“…The study showed that at an average of 16 months of follow-up, freedom from AF recurrence was present in 61 % of the patients who received CFAE ablation and PVI, 40 % of patients who received PVI and only 11 % of patients who received circumferential pulmonary vein ablation (p<0.001 for a three-way comparison). 64 Similarly, in the STAR-AF (Substrate and Trigger Ablation for Reduction of AF) trial, 100 patients with high burden paroxysmal or persistent AF were randomised to CFAE ablation alone, PVI alone or the combination of PVI and CFAE ablation. After one year of follow-up, the combination of PVI and CFAE ablation had the highest freedom from recurrent AF (74 %) compared with PVI alone (48 %) and CFAE ablation alone (29 %) (p=0.004).…”

Section: Limitations Of Targeting Rotors With Ablation For the Treatmmentioning

confidence: 99%

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

Waks

Josephson²

2014

Arrhythmia &Amp; Electrophysiology Review

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Atrial fibrillation (AF), the most common sustained arrhythmia, is a leading cause of stroke, and is associated with significant morbidity and mortality worldwide. Despite its frequency, clinical importance, and advances in technology and our knowledge of the molecular, ionic and physiological fundamentals of cardiac electrophysiology, our limited understanding of the mechanisms that initiate and sustain AF has prevented us from being able to truly cure this arrhythmia with antiarrhythmic drugs and/or ablation. This contrasts with other arrhythmias, such as AV nodal tachycardia or circus movement tachycardia using an accessory pathway, which have well-defined mechanisms and circuits that can be safely targeted with high rates of cure. The observations that AF may have different mechanisms in different patients, and that paroxysmal, persistent and permanent forms of AF may differ in how they are initiated and sustained, only serves to reinforce our lack of understanding of this ubiquitous arrhythmia. Historical Mechanisms of Atrial Fibrillation and the Multiple Wavelet HypothesisInterest and understanding of the mechanism of AF began to take form in the early 1900s. Given the chaotic and irregular nature of AF on the surface electrocardiogram, rapid firing of automatic atrial foci was considered a potential mechanism. However, after the seminal work of Mayer 1 , Mines 2 and Garrey 3 in laying the foundation for describing and understanding reentrant arrhythmias, atrial reentrant circuits emerged as the likely drivers of AF.4-7 Although these theories were conceptually sound, it was impossible to prove a specific mechanism with the technology of the time. Moe et al. demonstrated that it was probabilistically unlikely that a large number of simultaneous wavefronts would all die out simultaneously, and AF would therefore perpetuate. However, if the number of simultaneous wavelets were small and/or below a critical value (between 15 and 30 in Moe's computer model), 9 at some point all reentrant wavefronts would be simultaneously extinguished, and AF would therefore terminate. 8,9 Allessie et al. provided experimental evidence supporting this mechanism in a canine heart model of AF where four to six simultaneous reentrant wavelets were needed to sustain arrhythmia. 10 Further evidence supporting multiple wavelets in AF was demonstrated in a separate model, which evaluated the effect of various antiarrhythmic drugs on canine myocardium. This model demonstrated that termination of AF was associated with a reduction AbstractAtrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, yet our understanding of the mechanisms that initiate and sustain this arrhythmia remains quite poor. Over the last 50 years, various mechanisms of AF have been proposed, yet none has been consistently observed in both experimental studies and in humans. Recently, there has been increasing interest in understanding how spiral waves or rotors -which are specific, organised forms of functional reentry -su...

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“…In this patient population, the left atrial substrate plays a prominent role in AF maintenance. Staged ablation strategies involving additional linear ablation and/or complex fractionated atrial electrogram-based (CFAE) ablation have yielded superior results [51,53]. Recently, a small hypothesis-generating study by Mansour et al investigated an approach of cryoballoon PVI combined with conventional irrigated-RF based substrate modification in 22 participants with persistent AF.…”

Section: Persistent Afmentioning

confidence: 99%

Cryoballoon Ablation for Atrial Fibrillation

Andrade

Dubuc

Guerra

et al. 2012

Indian Pacing and Electrophysiology Journal

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Focal point-by-point radiofrequency catheter ablation has shown considerable success in the treatment of paroxysmal atrial fibrillation. However, it is not without limitations. Recent clinical and preclinical studies have demonstrated that cryothermal ablation using a balloon catheter (Artic Front©, Medtronic CryoCath LP) provides an effective alternative strategy to treating atrial fibrillation. The objective of this article is to review efficacy and safety data surrounding cryoballoon ablation for paroxysmal and persistent atrial fibrillation. In addition, a practical step-by-step approach to cryoballoon ablation is presented, while highlighting relevant literature regarding: 1) the rationale for adjunctive imaging, 2) selection of an appropriate cryoballoon size, 3) predictors of efficacy, 4) advanced trouble-shooting techniques, and 5) strategies to reduce procedural complications, such as phrenic nerve palsy.

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Ablation for longstanding permanent atrial fibrillation: Results from a randomized study comparing three different strategies

Cited by 263 publications

References 21 publications

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Stand-Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

Cryoballoon Ablation for Atrial Fibrillation

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