Catheter Ablation of Low-Voltage Areas for Persistent Atrial Fibrillation: Procedural Outcomes Using High-Density Voltage Mapping

Nery, Pablo B.; Alqarawi, Wael; Nair, Girish M.; Sadek, Mouhannad M.; Redpath, Calum J.; Golian, Mehrdad; Dawood, Wafa Al; Chen, Li; Hansom, Simon P.; Klein, Andres; Wells, George A.; Birnie, David H.

doi:10.1016/j.cjca.2020.03.040

Cited by 17 publications

(16 citation statements)

References 42 publications

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“…Although the outcomes of substrate-guided AF ablation have been reported in previous studies, they mostly involved comparison of substrate modification in addition to PVI with PVI alone [ 10 – 12 , 23 , 25 ]. Yang et al reported that a strategy of selective electrophysiological-guided atrial substrate modification (LVA ablation) in sinus rhythm after circumferential PVI was clinically more effective than the stepwise approach (roof line, MVI, and CFAE) for non-paroxysmal AF ablation in a non-randomized study [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, it is unclear whether completed linear ablation as a substrate modification of LA improves outcomes, especially in patients without documented atrial flutter (AFL) during the procedure. In contrast, several studies have reported that an additional LVA substrate modification targeting the damaged and arrhythmogenic atrial tissue is effective in improving the outcomes [ 10 – 12 ]; however, LVA ablation has not yet become the cornerstone of the PeAF ablation strategy. It is unclear which type of ablation strategy should be applied in patients with PeAF in addition to PVI in clinical practice [ 4 – 6 ].…”

Section: Introductionmentioning

confidence: 99%

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Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis

Suzuki

Kaneko

Fujita

et al. 2022

BMC Cardiovasc Disord

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Background The efficacy of pulmonary vein isolation (PVI) alone is not guaranteed for persistent atrial fibrillation (PeAF), and it is unclear which type of ablation approach should be applied in addition to PVI. This study aimed to compare outcomes and prognosis between empirical linear ablation and low-voltage area (LVA) ablation after PVI for PeAF. Methods We enrolled 128 patients with PeAF who were assigned to the linear ablation group (n = 64) and the LVA ablation group (n = 64) using a propensity score-matched model. After PVI and cardioversion, the patients underwent either empirical linear ablation or LVA ablation during sinus rhythm. All patients in the linear ablation group underwent both roof line and mitral valve isthmus (MVI) ablations. An electrical-guided ablation targeting LVA (< 0.5 mV) was performed in the LVA group. When there was no LVA in the LVA group, only PVI was applied. We compared the procedural outcomes and recurrence after ablation between the two groups. Results The baseline characteristics were well-balanced between the two groups. Fifty patients had LVA (22 and 28 patients in the linear and LVA groups). The roof and MVI lines were completed in 100% and 96.9% of the patients. During the mean follow-up of 279.5 ± 161.3 days, the LVA group had significantly lower recurrence than the linear group (15 patients [23%] vs. 29 patients [45%], p = 0.014). Thirty-five patients were prescribed antiarrhythmic drugs during the follow-up period (linear group, n = 17; LVA group, n = 18); amiodarone and bepridil were administered to most of the patients (15 and 17 patients, respectively). The difference in the prognosis was relevant among the patients with LVA, while this trend was not observed in those without LVA. The LVA ablation group demonstrated significantly lower radiofrequency energy and shorter procedural time compared to the linear ablation group. The recurrence of atrial flutter was more likely to occur in the linear group than in the LVA group (14 [22%] vs. 6 [9.4%], p = 0.052). Conclusion The electrophysiological-guided LVA ablation is more effective than empirical linear ablation in PeAF patients with LVA. Unnecessary empirical linear ablation might have a risk of iatrogenic gap and atrial flutter recurrence.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis

Suzuki

Kaneko

Fujita

et al. 2022

BMC Cardiovasc Disord

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“…Substrate definition and identification, and recognize patients who may benefit from the emerging techniques need further study to improve the CA results. Low-voltage area identification by high-density endocardial voltage mapping and fibrosis identification using cardiac magnetic resonance imaging may be effective approaches [ 22 , 23 ]. Some non-PV triggers have been proven to be involved in AF, including left atrial appendage (LAA), posterior wall, superior vena cava, coronary sinus, and CTI.…”

Section: Discussionmentioning

confidence: 99%

Optimal Catheter Ablation Strategy for Patients with Persistent Atrial Fibrillation and Heart Failure: A Retrospective Study

He²,

et al. 2022

Cardiology Research and Practice

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The optimal catheter ablation (CA) strategy for patients with persistent atrial fibrillation (PeAF) and heart failure (HF) remains uncertain. Between 2016 and 2020, 118 consecutive patients with PeAF and HF who underwent the CA procedure in two centers were retrospectively evaluated and divided into the pulmonary vein isolation (PVI)-only and PVI + additional ablation groups. Transthoracic echocardiography (TTE) was performed at baseline, one month, and 12 months after the CA procedure. The HF symptoms and left ventricular ejection fraction (LVEF) improvements were analyzed. Fifty-six patients underwent PVI only, and 62 patients received PVI with additional ablation. Compared with the baseline, a significant improvement in the LVEF and left atrial diameter postablation was observed in all patients. No significant HF improvement was detected in the PVI + additional ablation group than in the PVI-only group (74.2% vs. 71.4%, P = 0.736 ), but the procedure and ablation time were significantly longer (137.4 ± 7.5 vs. 123.1 ± 11.5 min, P = 0.001 ). There was no significant difference in the change in TTE parameters and the number of rehospitalizations. For patients with PeAF and HF, CA appears to improve left ventricular function. Additional ablation does not improve outcomes and has a significantly longer procedure time. Trial registration number is as follows: ChiCTR2100053745 (Chinese Clinical Trial Registry; https://www.chictr.org.cn/index.aspx).

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“…Thus, a personalized procedure according to the various degrees of atrial fibrosis should be considered. A previous study has also shown that individualized low voltage zone ablation based on high-density left atrial mapping can improve the outcomes of PersAF patients ( 5 ). This approach has also presented a similar result in the DECAAF study.…”

Section: Introductionmentioning

confidence: 97%

Assessing the impact of blocking distal coronary sinus-left atrial muscular connection on inducible rate of atrial fibrillation and follow-up recurrence in persistent atrial fibrillation patients with different fibrotic degrees of left atrial: A retrospective study

Zhang

Liu

Fang

et al. 2022

Front. Cardiovasc. Med.

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BackgroundThe musculature of the coronary sinus (CS), especially its distal connection with the post wall of the left atrial (LA), has been associated with the genesis and maintenance of atrial flutter (AFL) and atrial fibrillation (AF). However, the relative contributions of the distal coronary sinus (CSD)-LA connection to PersAF with various degrees of atrial fibrosis remain unknown.ObjectiveThis study aimed to explore the different roles of blocking the CSD-LA connection in the induction of acute AF and middle-term follow-up of recurrence among PersAF patients with various degrees of LA fibrosis.Methods and resultsA retrospective cohort of 71 patients with drug-refractory and symptomatic PersAF underwent ablation for the first time were studied. The population was divided into two groups according to disconnection of the CSD-LA or not. All patients enrolled accepted the unified ablation procedure (circumferential pulmonary vein isolation, non-pulmonary vein trigger ablation and ablation of the CSD-LA connection). Group A (n = 47) successfully blocked the CSD-LA electrical connection and Group B (n = 24) failed. Twenty-five patients could be induced into sustained AF in the Group A compared to 20 in the Group B (53.2 vs. 83.3%, p = 0.013). After a mean follow-up of 185 ± 8 days, 24 (33.8%) patients experienced atrial arrhythmia recurrences. The Group A had significantly fewer recurrences (25.5%) compared to Group B (50%). Meanwhile, in Group A, the ROC curve analysis suggested that in the case of blocking CSD-LA, low voltage area (LVA) of LA can act as a predictive factor for acute AF induction (AUC = 0.943, Cut-off = 0.190, P < 0.001) with sensitivity and specificity of 92.3 and 90.5%, and middle-term recurrence (AUC = 0.889, Cut-off = 0.196, P < 0.001) with sensitivity and specificity of 100 and 65.7%.ConclusionDisconnection of CSD-LA could reduce the inducible rate of acute AF and the recurrences of atrial arrhythmia during middle-term follow-up. The PersAF patients with CSD-LA muscular connection blocked, experienced a higher acute AF inducible rate with larger proportion of LVA of LA (≥19%) and a higher recurrent rate of atrial arrhythmias with a larger proportion of LA fibrosis (≥19.6%).

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Catheter Ablation of Low-Voltage Areas for Persistent Atrial Fibrillation: Procedural Outcomes Using High-Density Voltage Mapping

Cited by 17 publications

References 42 publications

Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis

Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis

Optimal Catheter Ablation Strategy for Patients with Persistent Atrial Fibrillation and Heart Failure: A Retrospective Study

Assessing the impact of blocking distal coronary sinus-left atrial muscular connection on inducible rate of atrial fibrillation and follow-up recurrence in persistent atrial fibrillation patients with different fibrotic degrees of left atrial: A retrospective study

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