Atrial Arrhythmias After Single-Ring Isolation of the Posterior Left Atrium and Pulmonary Veins for Atrial Fibrillation

Abstract

Background-Single-ring isolation of the posterior left atrium is feasible, but the incidence and mechanisms of postprocedural arrhythmias have not been described in detail. Methods and Results-The first 100 consecutive patients (58.8Ϯ11.2 years old, 80 male) who underwent single-ring isolation for atrial fibrillation (66 intermittent, 18 persistent, 16 long-standing persistent) were followed up for 9.1Ϯ4.5 months. Recurrences were diagnosed by clinical symptoms and Holter monitoring. Patients with recurrences of sustained atrial arrhythmia Ͼ3 months after the procedure were offered a repeat procedure and were studied to determine the mechanisms of recurrence. Forty-six patients (46%) experienced sustained postprocedural atrial arrhythmias (35 had atrial fibrillation, and 34 had atrial flutter). Of these, 34 required a second procedure 7.0Ϯ3.1 months after their initial procedure. Reconnection of the posterior left atrium was seen in all patients with atrial fibrillation. Atrial flutter was most commonly due to mitral isthmus-dependent macroreentry (nϭ8, cycle length 368Ϯ116 ms) or macroreentry through 2 gaps in the ring of lesions (nϭ6, cycle length 328Ϯ115 ms). Posterior left atrium reisolation was achieved at the second procedure in all patients. Atrial flutter was successfully ablated and rendered noninducible in all patients. Six months after their last procedure, the Kaplan-Meier estimate of freedom from recurrence for all 100 patients was 81Ϯ5%. Conclusions-Atrial

Feasibility of the Radiofrequency Hot Balloon Catheter for Isolation of the Posterior Left Atrium and Pulmonary Veins for the Treatment of Atrial Fibrillation

“…The central balloon temperature and the duration of RF energy delivery were determined according to the thickness of the wall (1.4 to 3.2 mm) and the location of esophagus ( Figure 2 [5][6][7][8] ). During a prior in vitro study, the temperature difference between the surface and the center of the balloon was 10.2Ϯ0.5°C.…”

“…Optimal positioning of the balloon was determined under the biplane fluoroscopic view (Figure 2 1,5,7,11 ). The contour of the inflated balloon showed the relationship between the balloon and the target tissue.…”

“…Based on such observation, radiofrequency (RF) catheter ablation of AF has been achieved by encircling each PV ostia using conventional ablation methods to electrically isolate the PVs. 3,4 Recently, developed techniques have been used to isolate the entire posterior left atrium (LA), including all PVs (so-called single ring isolation 5 and box isolation). 6 These approaches could decrease the risk of esophageal damage and eliminate the extra-PV foci at the posterior LA beyond the PV antra.…”

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…253,436,507,508,622,623, 624,625,630,870,871,995,996,997,998,999,1000,1001,1002 Most of these tachycardias originate in the LA, although RA cavotricuspid isthmus (CTI)-dependent flutters might also occur. Patients with a regular AT of new onset might complain of worsening symptoms due to a faster mean ventricular rate (frequently 2:1 ventricular response) than that during AF preablation.…”

Electrogram-Gated Radiofrequency Ablations With Duty Cycle Power Delivery Negate Effects of Ablation Catheter Motion

“…Without being able to predict a consistent lesion length as seen in gated ablations, it is extremely difficult to achieve a contiguous line of radiofrequency ablation lesions with no gaps in between lesions that are transmural. [20][21][22][23] For a given duration and power of ablations, lesion length created was highly variable and because we often have no means of quantifying or predicting the amount of catheter sliding motion occurring at any time point, lesion length is, therefore, unpredictable depending on the catheter sliding distance occurring at the time of lesion creation. Wider than expected lesions could potentially lead to unwanted radiofrequency energy delivery to structures, such as the AV node, conversely, thinner lesions may be more conducive to interlesion gaps leading to reconnections.…”