Inadvertent electrical isolation of the left atrial appendage during catheter ablation of persistent atrial fibrillation

Chan, Chin Pok; Wong, Wai Shun; Pumprueg, Satchana; Veerareddy, Srikar; Billakanty, Sreedhar R.; Ellis, Christopher R.; Chae, Sanders; Buerkel, Daniel M.; Aasbo, Johan D.; Crawford, Thomas; Good, Eric; Jongnarangsin, Krit; Ebinger, Matthew; Bogun, Frank; Pelosi, Frank; Oral, Hakan; Morady, Fred; Chugh, Aman

doi:10.1016/j.hrthm.2009.10.036

Cited by 39 publications

(49 citation statements)

References 18 publications

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“…13 Two major safety concerns arise when considering the techniques of LAA ablation. First, the thin aspects of the LAA wall may be prone to perforation.…”

Section: Panikker Et Almentioning

confidence: 99%

“…13 CS ablation may interrupt the distal leftward extension of the Bachmann bundle at the epicardial aspect of the mitral isthmus and, therefore, isolate part of the LAA. In addition, the adjuvant use of distal CS ablation when required may have contributed to our ability to achieve acute mitral valve isthmus block in all study cases.…”

Section: Procedural Feasibilitymentioning

confidence: 99%

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Left Atrial Appendage Electrical Isolation and Concomitant Device Occlusion to Treat Persistent Atrial Fibrillation

Panikker

Jarman

Virmani

et al. 2016

Circ: Arrhythmia and Electrophysiology

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Background— Left atrial appendage (LAA) electric isolation is reported to improve persistent atrial fibrillation (AF) ablation outcomes. However, loss of LAA mechanical function may increase thromboembolic risk. Concomitant LAA electric isolation and occlusion as part of conventional AF ablation has never been tested in humans. We therefore evaluated the feasibility, safety, and efficacy of LAA electric isolation and occlusion in patients undergoing long-standing persistent AF ablation. Methods and Results— Patients with long-standing persistent AF (age, 68±7 years; left atrium diameter, 46±3 mm; and AF duration, 25±15 months) underwent AF ablation, LAA electric isolation, and occlusion. Outcomes were compared with a balanced (1:2 ratio) control group who had AF ablation alone. Among 22 patients who underwent ablation, LAA electric isolation was possible in 20. Intraprocedural LAA reconnection occurred in 17 of 20 (85%) patients, predominantly at anterior and superior locations. All were reisolated. LAA occlusion was successful in all 20 patients. There were no major periprocedural complications. Imaging at 45 days and 9 months confirmed satisfactory device position and excluded pericardial effusion. One of twenty (5%) patients had a gap of ≥5 mm requiring anticoagulation. Nineteen of twenty (95%) patients stopped warfarin at 3 months. Without antiarrhythmic drugs, freedom from AF at 12 months after a single procedure was significantly higher in the study group (19/20, 95%) than in the control group (25/40, 63%), P =0.036. Freedom from atrial arrhythmias was demonstrated in 12 of 20 (60%) and 18 of 20 (90%) patients after 1 and ≤2 procedures (mean, 1.3), respectively. Conclusions— Persistent AF ablation, LAA electric isolation, and mechanical occlusion can be performed concomitantly. This technique may improve the success of persistent AF ablation while obviating the need for chronic anticoagulation. Clinical Trial Registration— URL: https://clinicaltrials.gov . Unique identifier: NCT02028130.

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“…13 Two major safety concerns arise when considering the techniques of LAA ablation. First, the thin aspects of the LAA wall may be prone to perforation.…”

Section: Panikker Et Almentioning

confidence: 99%

Section: Procedural Feasibilitymentioning

confidence: 99%

Left Atrial Appendage Electrical Isolation and Concomitant Device Occlusion to Treat Persistent Atrial Fibrillation

Panikker

Jarman

Virmani

et al. 2016

Circ: Arrhythmia and Electrophysiology

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“…[10][11][12] The most common non-PV trigger sites are the superior vena cava, the coronary sinus, the atrial septum, the posterior wall, the ligament of Marshall, and, more recently emphasized, the LAA. [12][13][14][15][16][17][18][19] It is important to consider that the Cox-Maze III surgery data have demonstrated a 90% success rate at maintaining sinus rhythm and a low incidence of thromboembolic events, and this procedure excludes or excises the LAA. 20 The surgical data and the experience and lessons learned by burning guided our group to consider the LAA as a target for ablation.…”

Section: See Article By Panikker Et Almentioning

confidence: 99%

Left Atrial Appendage After Electrical Isolation

Biase

2016

Circ: Arrhythmia and Electrophysiology

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T he left atrial appendage (LAA) has been considered for years as a less relevant part of the left atrium. During the years, its function and role have been extensively studied.The LAA is recognized as the major source (95%) of cardiac emboli in patients with nonvalvular atrial fibrillation (AF). In addition, the LAA has been shown to have important roles in atrial natriuretic peptide secretion and as an underreported trigger site of AF. [1][2][3][4][5][6][7] From an anatomic point of view, the LAA has a trabecular tubular shape with variable morphologies and derives from the embryonic left atrium as an outgrowth of the pulmonary veins. 6,7 See Article by Panikker et alCatheter ablation of AF is a valid therapeutic option for the treatment of AF and has been shown to be superior to antiarrhythmic drugs for maintaining sinus rhythm. 8,9 Pulmonary vein (PV) isolation is the primary target for ablation. 9 Procedural success rates vary depending on the experience of the operator and on the subtype of atrial fibrillation: higher in paroxysmal and lower in persistent and longstanding, persistent AF. Many patients continue to experience AF recurrences, despite permanent PV isolation. In such cases, several authors have identified additional targets for ablation outside the pulmonary veins, the so called non-PV triggers. 10-12The most common non-PV trigger sites are the superior vena cava, the coronary sinus, the atrial septum, the posterior wall, the ligament of Marshall, and, more recently emphasized, the LAA. [12][13][14][15][16][17][18][19] It is important to consider that the Cox-Maze III surgery data have demonstrated a 90% success rate at maintaining sinus rhythm and a low incidence of thromboembolic events, and this procedure excludes or excises the LAA. 20 The surgical data and the experience and lessons learned by burning guided our group to consider the LAA as a target for ablation.In our first series in 2010, we showed that LAA electric isolation rather than focal LAA ablation was the best strategy to maintain sinus rhythm at follow-up in a series of patients that failed previous procedures and showed sustained LAA firing. 12 We also showed that after electric isolation of the LAA, in ≈50% of cases, lifelong anticoagulation is recommended to reduce the risk of thromboembolic complications.12 To eliminate the need for lifelong anticoagulation, LAA closure devices could potentially be used. It is also important to note that based on the current recommendations, 9 discontinuation of oral anticoagulation (OAC) after successful ablation is allowed only in patients with a CHA 2 DS 2 -VASc score <2 and that the majority of patients with nonparoxysmal AF that may require LAA electric isolation have a CHA 2 DS 2 -VASc score ≥2.In this issue of the Journal, Panikker et al 21 sought to assess the feasibility, safety, and efficacy of concomitant LAA electric isolation and LAA occlusion with the Watchman closure device in 22 patients undergoing long-standing, persistent AF ablation. Outcomes were compared with a balanced...

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“…A recent case series highlights the fact that, in extensively ablated or diseased atria, LAA isolation can occur during ablation at anatomically distant sites. 4 Careful postprocedure analysis of the electrograms in this case revealed that LAA isolation likely occurred with the first lesion at the LAA ostium, …”

Section: Discussionmentioning

confidence: 74%

Restoration of Sinus Rhythm by Incarceration, not Elimination, of Focal Atrial Tachycardia in Left Atrial Substrate Post Atrial Fibrillation Ablation

Wilton

Miyazaki

Hocini

et al. 2011

Circ: Arrhythmia and Electrophysiology

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Inadvertent electrical isolation of the left atrial appendage during catheter ablation of persistent atrial fibrillation

Cited by 39 publications

References 18 publications

Left Atrial Appendage Electrical Isolation and Concomitant Device Occlusion to Treat Persistent Atrial Fibrillation

Left Atrial Appendage Electrical Isolation and Concomitant Device Occlusion to Treat Persistent Atrial Fibrillation

Left Atrial Appendage After Electrical Isolation

Restoration of Sinus Rhythm by Incarceration, not Elimination, of Focal Atrial Tachycardia in Left Atrial Substrate Post Atrial Fibrillation Ablation

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