Ablation of Superior Pulmonary Veins Compared to Ablation of All Four Pulmonary Veins:

Abstract

A staged superior PVs isolation approach confers equal success rates but with reduced radiofrequency energy delivery and fluoroscopy and procedure times compared to isolation of all PVs at the initial ablation attempt.

Staged Circumferential and Ostial Pulmonary Vein Ablation for the Treatment of Paroxysmal Atrial Fibrillation

“…Following AF cardioversion, all PVs were mapped with a 20‐mm Lasso circular electrode (Biosense Webster). Segmental ostial ablation of all not already isolated PVs was performed as previously described 16 . Endpoints were elimination of PV muscle conduction distal to the ablation site based on abolition or dissociation of distal PV potentials and demonstration of both entrance and exit block 16 .…”

“…Segmental ostial ablation of all not already isolated PVs was performed as previously described 16 . Endpoints were elimination of PV muscle conduction distal to the ablation site based on abolition or dissociation of distal PV potentials and demonstration of both entrance and exit block 16 . In an effort to avoid PV stenosis, care was taken to achieve PV isolation by mainly ablating at the antrum of the PV just outside the ostium whenever this was feasible (Fig.…”

Usefulness of Atrial Fibrillation Burden as a Predictor for Success of Pulmonary Vein Isolation

“…However, data on the success rate of PVI is controversial and depends on the experience of the center, the ablation technique as well as the definition of success and the duration of follow‐up. Several authors defined recurrence as AF lasting ≥30 seconds as documented by the event recorder (ER), 4,5 whereas another used the duration of AF ≥2 minutes 6 . Other studies used less rigorous definitions which were based on the clinical assessment and ambulatory ECG monitoring including symptomatic improvement, improvement in quality of life (QoL), and reduction in initial AF burden (AFB) 1,2,5,7,8 .…”

Is Isolation of All Four Pulmonary Veins Necessary in Patients with Paroxysmal Atrial Fibrillation?

“…Furthermore, the typical anatomy of four discrete PV orifices is found in 80% of the patients and at least 3% of individuals have been reported to present with a common left PV ostium 14 . In the authors' experience, a common orifice may be detected in at least 10% of the cases, 16 and the routine use of imaging technologies, like magnetic resonance and intracardiac ultrasound, may reveal that this percentage is actually higher. Thus, targeted superior PV ablation may by itself necessitate ablation of the adjacent inferior PV.…”

“…Inferior PVs are not only more difficult to ablate, they are also more prone to postablation ostial stenosis due to their thinner and less well‐developed myocardial sleeve, 11,12 although the use of intracardiac echocardiography may decrease this risk 13 . PV stenosis rates have a wide range between studies (2–40%) mainly due to different ablation sites (ostial vs distal ablation) and differing methodology for estimating postablation ostia 14–16 . Magnetic resonance imaging and spiral computed tomographic scanning have shown that although current disconnection techniques are associated with a minimal reduction of the PV ostial diameter (8%), 14 stenoses exceeding 50% may occur in up to 18% of cases, 15 whereas severe stenoses (>90%) are found in up to 2% of cases 5 .…”