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

Rostock, Thomas; Salukhe, Tushar V.; Hoffmann, Boris; Steven, Daniel; Berner, Imke; Müllerleile, Kai; Theis, C.; Bock, Karsten; Servatius, Helge; Sultan, Arian; Willems, Stephan

doi:10.1161/circep.113.001019

Cited by 22 publications

(16 citation statements)

References 23 publications

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“…[1][2][3][4][5][6] Limited data are available for patients with purely long-standing persistent AF (LSPAF). Arrhythmogenic substrate progression as a result of continuous AF duration inversely relates with the success rate of restoring sinus rhythm (SR) by ablation and favorable long-term outcome.…”

Section: Introductionmentioning

confidence: 99%

Sinus rhythm restoration and arrhythmia noninducibility are major predictors of arrhythmia-free outcome after ablation for long-standing persistent atrial fibrillation: A prospective study

et al. 2015

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Section: Introductionmentioning

confidence: 99%

Sinus rhythm restoration and arrhythmia noninducibility are major predictors of arrhythmia-free outcome after ablation for long-standing persistent atrial fibrillation: A prospective study

et al. 2015

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“…16 If the initial results are reproducible and durable, it would not only confirm that these AT are frequently our creation but also more importantly greatly simplify the ablation procedure and improve clinical outcomes. For the time being, the study by Rostock et al 12 should reinforce our commitment to prevent the occurrence of AT and also to tackle these tachycardias whenever they are encountered, even though it remains unclear whether the arrhythmias are due to the ablation strategy (us) or the patient's underlying substrate (them).…”

Section: Circ Arrhythm Electrophysiolmentioning

confidence: 98%

“…Amid this uncertainty, we receive a timely contribution from Rostock et al 12 in the current issue of the journal. The authors strived to determine the mechanistic and prognostic significance of ATs that were encountered during an ablation procedure for persistent AF.…”

Section: Article See P 1059mentioning

confidence: 99%

Atrial Tachycardia After Ablation of Persistent Atrial Fibrillation

Chugh

2013

Circ: Arrhythmia and Electrophysiology

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A rrhythmia recurrence after catheter ablation of persistent atrial fibrillation (AF) is not uncommon and frequently requires repeat ablation procedures. [1][2][3] However, the precise arrhythmia that recurs depends on the strategy that was used at the original session. Patients who undergo sole pulmonary vein (PV) isolation usually manifest recurrent AF. Patients who undergo substrate modification, in the form of electrogram based 4 or linear ablation, 5 frequently develop atrial tachycardia (AT) either during or after the procedure. Whether these organized arrhythmias represent underlying driver tachycardias that were responsible for maintaining AF or occur as a result of our intervention (that is, proarrhythmia) remains unresolved. Article see p 1059If we are truly unmasking underlying drivers, then our ablation strategy may be validated because it allows us to map and potentially eliminate sources of AF, which otherwise could not be identified during fibrillatory conduction. Alternatively, it is possible that substrate ablation, especially linear left atrial ablation, may result in macroreentrant ATs that were not present during or responsible for maintaining AF. In this case, either the original source(s) has been eliminated or simply grazed and is now supplanted by organized reentry related to zones of slow conduction created by ablation.The existing literature provides evidence for both hypotheses. A study using spectral analysis showed that the frequency (ie, the cycle length) of the AT that resulted after AF termination matched that of a spectral component that was already present in the baseline periodogram during AF.6 A follow-up study revealed that when linear ablation resulted in complete conduction block, it was accompanied by a decrease in the prevalence of these spectral components.7 These findings suggest that site-specific ATs may be present during ongoing AF, despite the fact that their frequency is lower than the dominant frequency during AF. These studies then support the contention that organized tachycardias are bound to be encountered after elimination of fibrillatory conduction and, therefore, are not brought on by ablation-related slowed conduction. They also imply that these underlying tachycardias may be responsible for maintaining AF in a hierarchical manner.However, there is also significant support for the competing argument that the ablation strategy determines whether organized reentrant arrhythmias will be encountered during or after ablation. For example, macroreentrant ATs using the mitral isthmus or the roof are frequently encountered when patients with paroxysmal AF undergo linear ablation, with 8 or without PV isolation.5 However, these tachycardias are rarely seen after simple antral PV isolation. If these ATs were truly responsible for maintaining AF, why is it possible to eliminate the arrhythmia in 90% of patients with paroxysmal AF 9 without ablation of the left atrial isthmi? An earlier study also showed that virtually all reentrant ATs originated from prior ablation ...

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“…In addition, extensive ablation scheme determining substrate modification, can often result in significant impairment of left atrial function and occurrence of postprocedural atrial tachycardias. 16,17 In the attempt to contribute to the challenging quest for the optimal ablation strategy in patients with persistent AF, Yang et al 18 in this issue of Circulation: Arrhythmia and Electrophysiology, describe a voltage-based approach for atrial substrate modification in patients with persistent or long-standing persistent AF undergoing transcatheter ablation. After pulmonary vein isolation plus cavotricuspid isthmus ablation, patients cardiovertable to sinus rhythm, underwent high-density bipolar mapping of the left atrium to identify low-voltage zones (defined as bipolar voltage range between 0.1 and 0.4 mV) and sites with abnormal electrograms suggestive of local conduction delay in what the authors call transitional zones (defined as bipolar voltage range between 0.4 and 1.3 mV).…”

Section: See Article By Yang Et Almentioning

confidence: 99%

Electrophysiologically Guided Substrate Modification During Sinus Rhythm

Gaïta

Castagno

2016

Circ: Arrhythmia and Electrophysiology

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A trial fibrillation, the most common sustained cardiac arrhythmia, has a complex and multifaceted pathophysiology. 1 The presence of a predisposing substrate, frequently encompassing atrial hypertrophy, fibrosis, and significant alterations of the extracellular matrix, is contributing to intra-atrial electric conduction delay as well as shortening and dispersion of atrial refractory periods. Triggers such as short-coupled supraventricular extrasystoles can initiate the arrhythmia acting on this pathological milieu with the potential contribution of modulating factors, such as the autonomic nervous system, ischemia, and hormones. See Article by Yang et alThe initial clinical experiences of transcatheter ablation of atrial fibrillation (AF) were reported 20 years ago almost simultaneously by different groups.2,3 Mimicking atrial debulking and compartmentalization provided by surgical techniques such as the classical Maze procedure, these transcatheter approaches aimed at substantial atrial substrate modification. A few years later, the recognition by Haïssaguerre et al 4 that most of the ectopic foci initiating AF were located in the pulmonary veins, shifted the attention of the electrophysiological community from substrate to triggers of the arrhythmia. The observation that ablation with local radiofrequency energy of the ectopic foci achieved 62% freedom from AF, paved the way for circumferential pulmonary vein isolation widespread use, which soon became the cornerstone of paroxysmal AF interventional treatment showing higher efficacy when compared with antiarrhythmic drugs. 5 However, in patients presenting with persistent AF, pulmonary vein isolation proved to be insufficient if used as stand-alone ablation strategy showing only modest long-term success rates. 6,7 These findings suggested the existence of a more complex electrophysiological substrate in patients with persistent AF with structures and mechanisms involved in facilitation and maintenance of the arrhythmia residing outside the pulmonary veins.8 As a consequence, efforts were redirected toward AF substrate modification with several non-pulmonary veins targets used as guidance for transcatheter ablation. Linear ablation between fixed anatomic structures (eg, left atrial roof and mitral isthmus) provided additional benefit to circumferential pulmonary vein isolation in patients with persistent AF. 9,10Subsequently, mapping and ablation of complex-fractionated atrial electrograms defined as either continuous reentry of the fibrillation waves into the same area or overlap of different wavelets entering the same area at different times, was proposed by Nademanee et al 11 as a new ablative approach aiming at AF substrate modification. Other groups studied the role of autonomic nervous system in AF pathophysiology investigating the curative effects of partial vagal denervation secondary to atrial ganglia transcatheter ablation. 12,13 In clinical practice, different combinations of these ablative approaches have been tested for the treatment of persistent...

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

Abstract: The patients were selected using the following inclusion criteria: persistent AF lasting for a minimum duration of 1 month before the procedure, a history of ≥1 attempt at electric cardioversion, AF © 2013 American Heart Association, Inc.

Cited by 22 publications

References 23 publications

Sinus rhythm restoration and arrhythmia noninducibility are major predictors of arrhythmia-free outcome after ablation for long-standing persistent atrial fibrillation: A prospective study

Sinus rhythm restoration and arrhythmia noninducibility are major predictors of arrhythmia-free outcome after ablation for long-standing persistent atrial fibrillation: A prospective study

Atrial Tachycardia After Ablation of Persistent Atrial Fibrillation

Electrophysiologically Guided Substrate Modification During Sinus Rhythm

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