Characterization, Mapping, and Catheter Ablation of Recurrent Atrial Tachycardias After Stepwise Ablation of Long-Lasting Persistent Atrial Fibrillation

Abstract

Background-Atrial tachycardias (AT) often occur after ablation of long-lasting persistent AF (CAF) and are difficult to treat conservatively. This study evaluated mechanisms and success rates of conventional mapping and catheter ablation of recurrent ATs occurring late after stepwise ablation of CAF. Methods and Results-A total of 320 patients underwent de novo ablation of CAF using a stepwise ablation approach in 2006 to 2007 at our institution. This study comprised patients who presented with recurrent ATs at their first redo procedure after initial de novo CAF ablation. All procedures were guided by conventional mapping techniques exclusively. Sixty-one patients (63Ϯ10 years, 14 women) presented with their clinical AT at their redo procedure 7.7Ϯ4.4 months after initial de novo CAF ablation. A total of 133 ATs (2.2Ϯ0.9 per patient) were mapped. Forty-four (72%) were due to reentry; 17 (28%) were focal ATs. Reentry ATs were mainly characterized as roof and perimitral flutter (43% and 34%, respectively). Focal ATs mainly originated from the great thoracic veins (pulmonary veins: 41%, coronary sinus: 23%). Forty-five (74%) patients had conduction recovery of at least 1 pulmonary vein (mean, 1.2Ϯ0.8).Overall, 124 (93%) ATs could be ablated successfully. The mean procedure duration was 181Ϯ59 minutes, with a mean fluoroscopy time of 45Ϯ21 minutes. After a mean follow-up of 21Ϯ4 months, 50 (82%) patients were free of any arrhythmia recurrences after a single redo procedure. Conclusions-Although late recurrent ATs may have complex mechanisms, catheter ablation guided exclusively by conventional techniques is highly effective with excellent acute and long-term success rates. (Circ Arrhythm Electrophysiol. 2010;3:160-169.)

Five-Year Follow-Up After Catheter Ablation of Persistent Atrial Fibrillation Using the Stepwise Approach and Prognostic Factors for Success

“…3 Several studies have shown that termination is predictive for long-term maintenance of SR. [19][20][21][22]33 O'Neill et al reported lower recurrence rates in patients with AF termination during index procedure (5% versus 39%). Termination to SR being associated with the highest single procedure success rate compared with AT or AF at the end of the procedure (42% versus 13% and 25%) was shown by Ammar et al In contrast, Elayi et al noted no impact of termination on SR maintenance.…”

“…Additionally, AT recurrences (often based on macroreentrant mechanisms) can more easily be targeted during repeat procedures and are associated with favorable outcome when compared with CA for AF. 24,33,34 Therefore, occurrence of AT can be considered a step forward to SR.…”

Prognostic Role of Subsequent Atrial Tachycardias Occurring During Ablation of Persistent Atrial Fibrillation

“…6,14 In case of macroreentrant ATs, linear ablation was performed, and the end point of bidirectional block was assessed and confirmed by differential pacing maneuvers after restoration of SR. Focal ATs were mapped by assessing the earliest endocardial activation in relation to P-wave onset or, if P-wave onset could not be clearly identified, to a fixed intracardiac electrogram. After AT termination, no attempt at arrhythmia reinduction was performed.…”

“…[1][2][3][4][5][6] Although arrhythmia recurrences after pulmonary vein (PV) isolation as the sole procedural strategy predominantly consist of AF, subsequent ATs represent approximately half of all recurrences after extensive biatrial substrate ablation. [1][2][3][4][7][8][9] Therefore, a proarrhythmogenic consequence of the ablation procedure itself by creating the basis for zones of slow conduction or enhanced electric automaticity has been proposed to cause these ATs.…”

Overdrive Pacing From Downstream Sites on Multielectrode Catheters to Rapidly Detect Fusion and to Diagnose Macroreentrant Atrial Arrhythmias

“…8,[12][13][14][15] Coffey et al 8 reported a strategy of detailed activation mapping followed by focused entrainment mapping of AF ablation-related ATs. Rostock et al 13 reported that 72% of persistent AF ablation-related ATs are macroreentrant and proposed a mapping strategy starting with entrainment mapping from up to 6 LA sites to establish the correct AT diagnosis. Steven et al 14 proposed a focused mapping strategy based on recognition of a number of biatrial activation patterns.…”