Characterization of Reentrant Circuits in Left Atrial Macroreentrant Tachycardia

Ouyang, Feifan; Ernst, Sabine; Vogtmann, Thomas; Goya, Masahiko; Volkmer, Marius; Schaumann, Anselm; Bänsch, Dietmar; Antz, Matthias; Kuck, Karl‐Heinz

doi:10.1161/01.cir.0000015077.12680.2e

Cited by 198 publications

(51 citation statements)

References 17 publications

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“…In our early experience using segmental PV isolation, the most common type of AT was a focal pattern originating from a segment of a previously isolated PV. 18 These findings are in agreement with the findings of Ouyang and colleagues 19 who found that more of 80% of left ATs had focal origin from the PV. In contrast, when linear ablation is performed in addition to PVI, the majority of AT are macroreentrant.…”

Section: Early Versus Late Recurrencesupporting

confidence: 90%

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Atrial Tachycardias Occurring After Atrial Fibrillation Ablation: Strategies for Mapping and Ablation

Mountantonakis¹,

Gerstenfeld²

2010

J.A.F.I.B

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The occurrence of left atrial tachycardias (AT) after catheter ablation for atrial fibrillation (AF) is common, especially after more extensive ablation of persistent AF. These AT are invariably symptomatic and often do not respond to medical therapy. The initial strategy involves ventricular rate control, cardioversion, and observation as some tachycardias may resolve with time. For persistent ATs, effective management frequently requires catheter intervention. Careful characterization of the tachycardia mechanism is essential in designing an effective ablation strategy that would also avoid further creation of pro-arrhythmic substrate. With this review, we summarize the incidence, mechanism, diagnosis and treatment of ATs occurring after AF ablation.tachycardias. Using this approach, AT incidence has ranged from 10% 9 to 30%. 3,8,10,11 When ablation of complex fractionated electrograms alone is performed, post ablation AT may occur in approximately 15-25% of patients.5, 12 With a more extensive ablation involving PVI isolation, empiric lines and electrogram based ablation all performed during the same procedure, the incidence of AT has been reported as high as 50%.3 , 7, 13, 14 Early versus Late Recurrence AT can occur early or late after AF ablation. Early ATs are defined as AT occurring within 3 months after ablation and late ATs those that occur after the 3 month post-ablation period. The incidence of AT is particularly high in the early period post ablation with 89% of all ATs occurring the first month, 9% in the second and 2% in the third month.13 Although early AT occurrence does predict late AT or recurrence of AF 13, 15 approx imately one-third of tachycardias may resolve with conservative management. 16 The presence of hypertension, persistent AF, left atrial (LA) size>4 cm, presence of structural heart disease and the lack of a successful ablation of all targeted PV have been independently correlated with early atrial tachyarrhythmias occurrence. 16,17 The much higher incidence of AT during the early post-ablation period may partially be related to radiofrequency related inflammatory changes. Until the development of well defined fibrosis, tissue edema and inflammation can be pro-arrhythmic. In addition, like in all cases of acute local cardiac inflammation, ablation is likely to mount a systemic inflammatory response. Inflammation both at tissue and systemic levels are related to the development of arrhythmias. ATs that persist after a 3 month period or occur late after AF ablation typically do not usually resolve spontaneously and warrant intervention. 13 Mechanism and PreventionPost ablation ATs can be divided based on their mechanism as focal or macro-reentrant [ Figure 1]. The mechanism of AT is usually related to the www.jafib.com

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Section: Early Versus Late Recurrencesupporting

confidence: 90%

“…19 Therefore, we examine all previously created lines for reconnected segments and look for low amplitude, fragmented or double potentials that represent slow conduction. In our experience and others, the reentry circuit with a protected isthmus can be identified in …”

Section: Electrophysiologic Study -Diagnostic Maneuversmentioning

confidence: 99%

Atrial Tachycardias Occurring After Atrial Fibrillation Ablation: Strategies for Mapping and Ablation

Mountantonakis¹,

Gerstenfeld²

2010

J.A.F.I.B

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“…9,11 Mapping was performed with a 3.5-mm-tip catheter (ThermoCool Navi-Star, Biosense-Webster) during coronary sinus pacing or sinus rhythm. In case of AF, sinus rhythm was restored by external cardioversion.…”

Section: D Electroanatomic Mapping and Irrigated Radiofrequency Ablamentioning

confidence: 99%

Complete Isolation of Left Atrium Surrounding the Pulmonary Veins

et al. 2004

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Background-Paroxysmal atrial fibrillation (PAF) can be eliminated with continuous circular lesions (CCLs) around the pulmonary veins (PVs), but it is unclear whether all PVs are completely isolated. Methods and Results-Forty-one patients with symptomatic PAF underwent 3D mapping, and all PV ostia were marked on the 3D map based on venography. Irrigated radiofrequency energy was applied at a distance from the PV ostia guided by 2 Lasso catheters placed within the ipsilateral superior and inferior PVs. The mean radiofrequency duration was 1550Ϯ511 seconds for left-sided PVs and 1512Ϯ506 seconds for right-sided PVs. After isolation, automatic activity was observed in the right-sided PVs in 87.8% and in the left-sided PVs in 80.5%. During the procedure, a spontaneous or induced PV tachycardia (PVT) with a cycle length of 189Ϯ29 ms was observed in 19 patients. During a mean follow-up of 6 months, atrial tachyarrhythmias recurred in 10 patients. Nine patients underwent a repeat procedure. Conduction gaps in the left CCL in 9 patients and in the right CCL in 2 patients were closed during the second procedure. A spontaneous PVT with a cycle length of 212Ϯ44 ms was demonstrated in 7 of 9 patients, even though no PVT had been observed in 6 of these 7 patients during the first procedure. No AF recurred in 39 patients after PV isolation during follow-up. Conclusions-Automatic activity and fast tachycardia within the PVs could reflect an arrhythmogenic substrate in patients with PAF, which could be eliminated by isolating all PVs with CCLs guided by 3D mapping and the double-Lasso technique in the majority of patients.

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“…Successful ablation of macroreentrant AT with few RF applications in most patients indicates that the gaps responsible for AT were small and the critical isthmus was narrow, as recently reported. 16 Applications of RF energy on the earliest activation site also eliminated focal AT in most patients without complication.…”

Section: Catheter Ablation Results In Patients With Postablation Atmentioning

confidence: 97%

Prevention of Iatrogenic Atrial Tachycardia After Ablation of Atrial Fibrillation

et al. 2004

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Background-Circumferential pulmonary vein ablation (CPVA) is effective in curing atrial fibrillation (AF), but new-onset left atrial tachycardia (AT) is a potential complication. We evaluated whether a modified CPVA approach including additional ablation lines on posterior wall and the mitral isthmus would reduce the incidence of AT after PV ablation. Methods and Results-A total of 560 patients (291 men, 52%; age, 56.5Ϯ7.3 years) entered the study; 280 were randomized to CPVA alone (group 1) and 280 to modified CPVA (group 2). The primary end point was freedom from AT after the procedure. In group 1, 28 patients (10%) experienced new-onset AT, and 41 (14.3%) experienced recurrent AF. In group 2, 11 patients (3.9%) experienced AT, and 36 (12.9%) had recurrent AF. Group 1 was more likely to experience AT than group 2 (Pϭ0.005). Freedom from AF after ablation was similar in both groups (Pϭ0.57). Among those in group 1, gap-related macroreentrant AT was documented in 23 of the 28 patients (82%), and focal AT was found in 5 (18%). In group 2, gap-related macroreentrant AT was found in 8 of the 11 patients (73%), and focal AT was seen in 3 (27%). Two patients in group 1 and 1 patient in group 2 had both AT and AF. The strongest predictor of AT was the presence of gaps (PϽ0.001). Conclusions-Modified

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Characterization of Reentrant Circuits in Left Atrial Macroreentrant Tachycardia

Cited by 198 publications

References 17 publications

Atrial Tachycardias Occurring After Atrial Fibrillation Ablation: Strategies for Mapping and Ablation

Atrial Tachycardias Occurring After Atrial Fibrillation Ablation: Strategies for Mapping and Ablation

Complete Isolation of Left Atrium Surrounding the Pulmonary Veins

Prevention of Iatrogenic Atrial Tachycardia After Ablation of Atrial Fibrillation

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