HEartLight guided – PUre Pulmonary Vein Isolation Regardless of Concomitant Atrial Substrate: HEURECA Study

Abstract

Background It remains unclear whether left atrial low‐voltage area (LALVA) affects atrial tachyarrhythmia recurrence after laser balloon pulmonary vein isolation (PVI) for atrial fibrillation (AF). We prospectively evaluated the outcome of laser balloon PVI in patients with and without LALVA (≤ 0.5 mV) together with surface/intracardiac electrophysiological criteria. Methods One hundred consecutive paroxysmal/persistent AF patients underwent laser balloon PVI. The relative extent of LALVA (extent of LALVA/left atrial surface area × 100 [%]: rLALVA), total p‐wave duration in lead II (PWD), and time interval from the beginning of p‐wave to the local activation in left atrial appendage (TTLAA) were assessed. Patients were divided into patients with LALVA (group A: 23 patients) and those without LALVA (group B: 77 patients). The primary endpoint was freedom from atrial tachyarrhythmia after the blanking periods. Results Complete PVI was achieved in 99/100 (99%) patients. PWD and TTLAA were longer in group A (both, P < 0.001). During 12 months’ follow‐up, survival free from atrial tachyarrhythmia recurrence was lower in group A (12/23 [52%] patients vs 67/77 [87%] patients, P < 0.001). Multivariate analysis identified rLALVA as the only independent predictor of atrial tachyarrhythmia recurrence. rLALVA correlated with PWD and TTLAA (r = 0.41, P < 0.001 and r = 0.60, P < 0.001, respectively). Receiver operating characteristic curve for rLALVA revealed PWD of 122 ms and TTLAA of 92 ms as the optimal cut‐off value. Conclusion LALVA was associated with poorer outcome after laser balloon PVI. Patients may be identified by longer PWD and TTLAA.

Findings from repeat ablation using high-density mapping after pulmonary vein isolation with pulsed field ablation

“…Our group also reported the low incidence of lesion set related AT after contemporary balloon-based ablations. 17 , 18 Unexpectedly, lesion set associated AT was frequently observed in our study. The presence of proarrhythmic substrate was reported to be associated with post-ablation macro-reentry circuits.…”

“…The presence of proarrhythmic substrate was reported to be associated with post-ablation macro-reentry circuits. 18–20 Such substrate is theoretically based on either lesion set related- or pre-existing scar lesion represented by LVA. Considering the distribution of LVA, the critical isthmus of the AT was linked to the PVI lesion set of the index procedure at the LAPW in the majority of cases ( Figure 5A ), while two types of isolated surface lesion on PW were observed in patients with other types of recurrent ATa; (i) the distance on PW between isolated border zone was wide enough to avoid a potential slow conduction corridor on PW ( Figure 5B ); (ii) septal and lateral ablated antral lesions were fused at the LA roof and connected to LVA at the anterior lesion ( Figure 5C and D ), which blocked unintentionally a roof line.…”

“…Fifth, LVA was determined according to a report of variable cut-off points in different rhythms. 18 The cut-off point of LVA was based on the report demonstrating its correlation among different rhythms, which has not been yet widely established. Finally, the gap location was based on combination of information from 3D mapping system and electrophysiological findings.…”