Isolation of the Posterior Left Atrium for Patients with Persistent Atrial Fibrillation: Routine Adenosine Challenge for Dormant Posterior Left Atrial Conduction Improves Long-Term Outcome

McLellan, A.; Prabhu, Sandeep; Voskoboinik, A.; Wong, Maria M.; Walters, Tomos E.; Pathik, B.; Morris, Gwilym M.; Nisbet, Ashley; Lee, G.; Morton, Joseph B.; Kalman, Jonathan M.; Kistler, P.

doi:10.1016/j.hlc.2016.06.351

Cited by 11 publications

(22 citation statements)

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“…This depends on a selective action on pulmonary veins, where it hyperpolarizes pulmonary venous myocytes by increasing adenosine-sensitive potassium current (IKAdo), an effect it does not have on atrial myocardium.This can restore excitability by removing voltage-dependent sodium channel inactivation 23. A similar effect on reconnection of the pulmonary venous component has been clinically observed in one study, with adenosine-induced transient reconnection of the pulmonary venous component reported in 17%, and a comparable pulmonary vein reconnection rate of 11% 24. Isolated neurons and even small ganglia have been found between atrial muscle fascicles, including the pulmonary vein sleeves.…”

supporting

confidence: 62%

“…The first approach to isolating the pulmonary venous component, the socalled 'box' lesion, connects bilateral pulmonary vein-encircling lesions by placing two linear lesions connecting the superior and inferior ends of both lesion sets to one another. 7,24 While this delivers less radiofrequency (RF) energy, gaps or reconnection across either line can lead to its failure. 9,10 The second approach is ablation or debulking of the tissue between both pulmonary vein lesion sets, further extended by some operators to the true posterior wall down to the level of the coronary sinus, with the endpoint of abolishing electrical activity between the veins.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

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The rationale for isolation of the left atrial pulmonary venous component to control atrial fibrillation: A review article

et al. 2019

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supporting

confidence: 62%

Section: Accepted Manuscriptmentioning

confidence: 99%

The rationale for isolation of the left atrial pulmonary venous component to control atrial fibrillation: A review article

et al. 2019

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“…The studies on atrial arrhythmia which have not implicitly categorized persistent AF were not included in this study 4,7‐9 . The cohort study on isolation of the posterior left atrium and PVI for patients with persistent atrial fibrillation was excluded as it was done with adenosine challenge 10 . Furthermore, the case‐series did not meet the eligibility criteria for this meta‐analysis 11‐15 .…”

Section: Methodsmentioning

confidence: 99%

Clinical outcomes of adjunctive posterior wall isolation in persistent atrial fibrillation: A meta‐analysis

Salih

Darrat²,

Ibrahim

et al. 2020

Cardiovasc electrophysiol

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Background: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation but the recurrence rate remains relatively high in persistent patients with AF. Therefore, posterior wall isolation (PWI) in addition to PVI has been proposed to increase freedom from AF.Objective: To evaluate the success of adjunctive PWI in persistent AF. Methods:We searched electronic database using specific terms. The primary outcomes are recurrence rate of AF and recurrence of atrial arrhythmias. The secondary outcomes were atrial flutter/tachycardia (AFL/AT), procedure time, fluoroscopy time, and procedure related complications. Estimated risk ratios (RRs) and 95% confidence intervals (CIs) were evaluated.Results: Six studies were included (1334 patients with persistent AF). Adjunctive PWI resulted in a significant reduction in the recurrence rate of AF compared with patients who had PVI only (19.8% vs 29.1%; RR, 0.64; 95% CI, 0.42-0.97; P < .04; I 2 = 76%). There was a significant reduction in the recurrence rate of all atrial arrhythmia (30.8% vs 41.1%; RR, 0.75; 95% CI, 0.60-0.94; P < .01; I 2 = 60%). Compared with PVI only, adjunctive PWI did not increase the rate of AFL or AT (11.6% vs 13.9%; RR, 0.85; 95% CI, 0.54-1.32; P < .46; I 2 = 47%) or the rate of procedure related complications (4.6% vs 3.6%; RR, 1.25; 95% CI, 0.72-2.17; P < .44; I 2 = 0%). Conclusion:In patients with persistent AF, adjunctive PWI was associated with decreased recurrence of AF and atrial arrhythmias compared with PVI alone without an increased risk of AFL or AT or procedure related complications. K E Y W O R D Satrial fibrillation, atrial flutter, meta-analysis, posterior wall isolation, pulmonary vein isolation 1 | BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia, with a prevalence of 0.5% to 1% of the population, 1 and is expected to rise even more over the next decades. 2 Historically management of AF has been geared toward rate control, or rhythm control with antiarrhythmic drugs. Over the last two decades, catheter ablation has emerged as an alternative for rhythm control with medications and is now a recognized first line therapy for the treatment of AF in select populations. This is emphasized for instance in the recent American College of Cardiology updated guidelines, which states that catheter ablation may be used in selected patients with symptomatic AF and heart failure with low ejection fraction based on data to support reduced hospitalization and potentially even reduce mortality. 3

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“…The area between the pulmonary veins, commonly referred to as the left atrial posterior wall, is derived embryologically from the initial common pulmonary vein . It has been found to be one of the commonest sources of non‐PV triggers, and displays similar electrophysiological properties to pulmonary venous tissue, including the response to adenosine, as well as anisotropic conduction due to fiber orientation . In an anatomical sense, the pulmonary venous component (PV‐Comp) of the left atrium constitutes the dome, or superior aspect, of the left atrium, whereas the true left atrial posterior wall extends from the level of the lower border of the inferior pulmonary veins to the vestibule.…”

Section: Introductionmentioning

confidence: 99%

Isolating the entire pulmonary venous component versus isolating the pulmonary veins for persistent atrial fibrillation: A propensity‐matched analysis

Elbatran

Gallagher

et al. 2019

Pacing Clinical Electrophis

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Background: The outcomes of pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) are suboptimal. The entire pulmonary venous component (PV-Comp), consisting of the pulmonary veins, their antra, and the area between the antra, provides triggers and substrate for AF. PV-Comp isolation is an alternative strategy for persistent AF ablation. Methods: Among 328 patients with persistent AF who underwent a first radiofrequency ablation procedure, 200 patients (PVI, n = 100; PV-Comp isolation, n = 100) were selected by propensity score matching. Both groups were followed up for 1 year. Results: At 6-and 12-month follow-up, atrial tachyarrhythmia (AF/atrial tachycardia) recurred in 41 and 61 patients in PVI group and 22 (P = .006) and 33 patients (P < .001) in PV-Comp isolation group, respectively. PV-Comp isolation was associated with longer mean time to recurrence (PVI: 8 months, PV-Comp isolation: 10 months, log-rank P < .001) and a lower probability of recurrence (odds ratio [OR] = 0.32; 95% confidence of interval [CI] = 0.18-0.56, P < .001), with no increase in procedural complications (PVI: 5 of 100, PV-Comp isolation: 6 of 100, P = .76). Procedure duration was longer in PV-Comp isolation group (PVI: 186 ± 42 min, PV-Comp isolation: 238 ± 44 min, P < .001), as well as fluoroscopy time (PVI: 22 ± 16 min, PV-Comp isolation: 31 ± 21 min, P = .001). Conclusion: PV-Comp isolation for persistent AF reduced atrial tachyarrhythmia recurrence up to 1 year compared with PVI alone. While procedure and fluoroscopy time increased, there was no difference in procedural complications. K E Y W O R D S catheter ablation, persistent atrial fibrillation, posterior wall isolation, pulmonary vein isolation, pulmonary venous component

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Isolation of the Posterior Left Atrium for Patients with Persistent Atrial Fibrillation: Routine Adenosine Challenge for Dormant Posterior Left Atrial Conduction Improves Long-Term Outcome

Cited by 11 publications

References 0 publications

The rationale for isolation of the left atrial pulmonary venous component to control atrial fibrillation: A review article

The rationale for isolation of the left atrial pulmonary venous component to control atrial fibrillation: A review article

Clinical outcomes of adjunctive posterior wall isolation in persistent atrial fibrillation: A meta‐analysis

Isolating the entire pulmonary venous component versus isolating the pulmonary veins for persistent atrial fibrillation: A propensity‐matched analysis

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