Ablation of persistent atrial fibrillation: Challenges and solutions

Terricabras, María; Piccini, Jonathan P.

doi:10.1111/jce.14311

Cited by 19 publications

(7 citation statements)

References 81 publications

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“…The outcome of ablation in patients with persistent AF has been shown to be consistently poorer than that of PAF patients 12 . This may be related to the presence of non‐pulmonary vein substrate or the lack of durable lesions when ablating 12 . It may be the case that newer advanced ablation technologies or techniques may improve the outcomes in these patients.…”

Section: Discussionmentioning

confidence: 99%

Long Term outcomes of percutaneous atrial fibrillation ablation in patients with continuous monitoring

Sulke

Dulai

Freemantle

et al. 2021

Pacing Clinical Electrophis

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Introduction: There is limited data using continuous monitoring to assess outcomes of atrial fibrillation (AF) ablation. This study assessed long‐term outcomes of AF ablation in patients with implantable cardiac devices. Methods: 207 patients (mean age 68.1 ± 9.5, 50.3% men) undergoing ablation for symptomatic AF were followed up for a mean period of 924.5 ± 636.7 days. Techniques included The Pulmonary Vein Ablation Catheter (PVAC) (59.4%), cryoablation (17.4%), point by point (14.0%) and The Novel Irrigated Multipolar Radiofrequency Ablation Catheter (nMARQ) (9.2%). Results: 130 (62.8%) patients had paroxysmal AF (PAF) and 77 (37.2%) persistent AF. First ablation and repeat ablation reduced AF burden significantly (relative risk 0.91, [95% CI 0.89 to 0.94]; P <0.0001 and 0.90, [95% CI, 0.86–0.94]; P <0.0001). Median AF burden in PAF patients reduced from 1.05% (interquartile range [IQR], 0.1%‐8.70%) to 0.10% ([IQR], 0%‐2.28%) at one year and this was maintained out to four‐years. Persistent AF burden reduced from 99.9% ([IQR], 51.53%‐100%) to 0.30% ([IQR], 0%‐77.25%) at one year increasing to 87.3% ([IQR], 4.25%‐100%) after four years. If a second ablation was required, point‐by‐point ablation achieved greater reduction in AF burden (relative risk, 0.77 [95% CI, 0.65–0.91]; P <0.01). Conclusion: Ablation reduces AF burden both acutely and in the long‐term. If a second ablation was required the point‐by‐point technique achieved greater reductions in AF burden than “single‐shot” technologies. Persistent AF burden increased to near pre ablation levels by year 4 suggesting a different mechanism from PAF patients where this increase did not occur.

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Section: Discussionmentioning

confidence: 99%

Long Term outcomes of percutaneous atrial fibrillation ablation in patients with continuous monitoring

Sulke

Dulai

Freemantle

et al. 2021

Pacing Clinical Electrophis

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“… 31 , 37 , 38 Nonetheless, the efficacy of catheter ablation remains suboptimal, 39 , 40 largely due to a one-size-fits-most approach. For example, in patients with persistent AF, 41 arrhythmia-free survival rates after a single procedure were 35.3 ± 3.9%, 28.0 ± 3.7%, and 16.8 ± 3.2% at 1, 2, and 5 years, respectively. 42 Time to AF recurrence is a major determinant of AF outcome, where patients with later recurrences were more likely to have sporadic episodes and respond better to AADs and repeat ablation.…”

Section: Clinical Challenges In Af Management Potentially Benefiting From Computational Modellingmentioning

confidence: 99%

Computational models of atrial fibrillation: achievements, challenges, and perspectives for improving clinical care

Heijman

Sutanto

Crijns

et al. 2021

Cardiovascular Research

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Despite significant advances in its detection, understanding and management, atrial fibrillation (AF) remains a highly prevalent cardiac arrhythmia with major impact on morbidity and mortality of millions of patients. AF results from complex, dynamic interactions between risk factors and comorbidities that induce diverse atrial remodeling processes. Atrial remodeling increases AF vulnerability and persistence, while promoting disease progression. The variability in presentation and wide range of mechanisms involved in initiation, maintenance and progression of AF, as well as its associated adverse outcomes, make the early identification of causal factors modifiable with therapeutic interventions challenging, likely contributing to suboptimal efficacy of current AF management. Computational modeling facilitates the multilevel integration of multiple datasets and offers new opportunities for mechanistic understanding, risk prediction and personalized therapy. Mathematical simulations of cardiac electrophysiology have been around for 60 years and are being increasingly used to improve our understanding of AF mechanisms and guide AF therapy. This narrative review focuses on the emerging and future applications of computational modeling in AF management. We summarize clinical challenges that may benefit from computational modeling, provide an overview of the different in silico approaches that are available together with their notable achievements, and discuss the major limitations that hinder the routine clinical application of these approaches. Finally, future perspectives are addressed. With the rapid progress in electronic technologies including computing, clinical applications of computational modeling are advancing rapidly. We expect that their application will progressively increase in prominence, especially if their added value can be demonstrated in clinical trials.

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“…High power–short duration ablation is a novel technique that offers a theoretical advantage due to a reduction in the time-dependent conductive heating phase of lesion formation with less consequent collateral tissue damage [ 92 ]. In swine, high power–short duration ablation at 90 Watts results in more contiguous lesions than conventional ablation with a wider diameter but shallower depth [ 93 ].…”

Section: Future Perspectivesmentioning

confidence: 99%

Catheter Ablation in Persistent AF, the Evolution towards a More Pragmatic Strategy

O’Neill

Wielandts

Gillis

et al. 2021

JCM

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Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and represents a heterogeneous disorder with a complex pathological basis. While significant technological advances have taken place over the last decade in the field of catheter ablation of AF, response to ablation varies and long-term success rates in those with persistent AF remain modest. Mechanistic studies have highlighted potentially different sustaining factors for AF in the persistent AF population with substrate-driven focal and re-entrant sources in the body of the atria identified on invasive and non-invasive mapping studies. Translation to clinical practice, however, remains challenging and the application of such mapping techniques to clinical ablation has yet to demonstrate a significant benefit beyond pulmonary vein isolation (PVI) alone in the persistent AF cohort. Recent advances in catheter and ablation technology have centered on improving the durability of ablation lesions at index procedure and although encouraging results have been demonstrated with early studies, large-scale trials are awaited. Further meaningful improvement in clinical outcomes in the persistent AF population requires ongoing advancement in the understanding of AF mechanisms, coupled with continuing progress in catheter technology capable of delivering durable transmural lesions.

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Ablation of persistent atrial fibrillation: Challenges and solutions

Cited by 19 publications

References 81 publications

Long Term outcomes of percutaneous atrial fibrillation ablation in patients with continuous monitoring

Long Term outcomes of percutaneous atrial fibrillation ablation in patients with continuous monitoring

Computational models of atrial fibrillation: achievements, challenges, and perspectives for improving clinical care

Catheter Ablation in Persistent AF, the Evolution towards a More Pragmatic Strategy

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