Long-standing Persistent Atrial Fibrillation Ablation: How do You Perform it?

Authors

  • Jeffrey Smietana Hospital of University of Pennsylvania – Cardiovascular Division – Electrophysiology Section – Philadelphia/Pennsylvania – United States of America. https://orcid.org/0000-0002-7537-4643
  • Pasquale Santangeli Hospital of University of Pennsylvania – Cardiovascular Division – Electrophysiology Section – Philadelphia/Pennsylvania – United States of America.

Keywords:

Arrhythmia; Atrial fibrillation; Catheter ablation; Nonpulmonary vein trigger.

Abstract

Catheter ablation of long-standing persistent atrial fibrillation (LSPAF) presents unique challenges and the lack of large body of evidence surrounding management makes for disagreement and different approaches for treatment. Outlined is a case example that offers a comprehensive approach to ablation in patients with LSPAF that consists of risk factor management, an ablation strategy, a rigorous trigger protocol and follow-up rhythm monitoring. The case presented highlights management of this difficult population as best guided by current evidence and our experience. Ablation treatment and management strategies will continue to evolve with further randomized data and the advent of improved ablation technologies.

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References

Santangeli P, Zado ES, Hutchinson MD, et al. Prevalence and distribution of focal triggers in persistent and long-standing persistent atrial fibrillation. Heart Rhythm. 2016;13(2):374–382. doi:10.1016/j.hrthm.2015.10.023

Verma A, Jiang CY, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015;372(19):1812–1822. doi:10.1056/NEJMoa1408288

Hayashi K, An Y, Nagashima M, et al. Importance of nonpulmonary vein foci in catheter ablation for paroxysmal atrial fibrillation. Heart Rhythm. 2015;12(9):1918–1924. doi:10.1016/j.hrthm.2015.05.003

Santangeli P, Marchlinski FE. Techniques for the provocation, localization, and ablation of non-pulmonary vein triggers for atrial fibrillation. Heart Rhythm. 2017;14(7):1087–1096. doi:10.1016/j.hrthm.2017.02.030

Yaeger A, Cash NR, Parham T, et al. A Nurse-Led Limited Risk Factor Modification Program to Address Obesity and Obstructive Sleep Apnea in Atrial Fibrillation Patients. J Am Heart Assoc. 2018;7(23):e010414. doi:10.1161/JAHA.118.010414

Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study. J Am Coll Cardiol. 2014;64(21):2222‐2231. doi:10.1016/j.jacc.2014.09.028

Hutchinson MD, Garcia FC, Mandel JE, et al. Efforts to enhance catheter stability improve atrial fibrillation ablation outcome. Heart Rhythm. 2013;10(3):347‐353. doi:10.1016/j.hrthm.2012.10.044

Mountantonakis SE, Elkassabany N, Kondapalli L, Marchlinski FE, Mandel JE, Hutchinson MD. Provocation of atrial fibrillation triggers during ablation: does the use of general anesthesia affect inducibility?. J Cardiovasc Electrophysiol. 2015;26(1):16‐20. doi:10.1111/jce.12512

Winkle RA, Mohanty S, Patrawala RA, et al. Low complication rates using high power (45-50 W) for short duration for atrial fibrillation ablations. Heart Rhythm. 2019;16(2):165‐169. doi:10.1016/j.hrthm.2018.11.031

Berte B, Hilfiker G, Moccetti F, et al. Pulmonary vein isolation using ablation index vs. CLOSE protocol with a surround flow ablation catheter. Europace. 2020;22(1):84‐89. doi:10.1093/europace/euz244

Bourier F, Duchateau J, Vlachos K, et al. High-power short-duration versus standard radiofrequency ablation: Insights on lesion metrics. J Cardiovasc Electrophysiol. 2018;29(11):1570‐1575. doi:10.1111/jce.13724

Bhaskaran A, Chik W, Pouliopoulos J, et al. Five seconds of 50-60 W radio frequency atrial ablations were transmural and safe: an in vitro mechanistic assessment and force-controlled in vivo validation. Europace. 2017;19(5):874‐880. doi:10.1093/europace/euw077

Bai R, Di Biase L, Mohanty P, et al. Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation. Heart Rhythm. 2016;13(1):132‐140. doi:10.1016/j.hrthm.2015.08.019

Lee JM, Shim J, Park J, et al. The Electrical Isolation of the Left Atrial Posterior Wall in Catheter Ablation of Persistent Atrial Fibrillation. JACC Clin Electrophysiol. 2019;5(11):1253‐1261. doi:10.1016/j.jacep.2019.08.021

De Lurgio D, Crossen K, Jaswinder G, et al. Convergence of Epicardial and Endocardial RF Ablation for the Treatment of Symptomatic Persistent AF. Heart Rhythm 2020 (Late-Breaking Clinical Trials). Presented at the Annual Scientific Sessions of the Heart Rhythm Society, Online, May 2020

Jeevanantham V, Ntim W, Navaneethan SD, et al. Meta-analysis of the effect of radiofrequency catheter ablation on left atrial size, volumes and function in patients with atrial fibrillation. Am J Cardiol. 2010;105(9):1317‐1326. doi:10.1016/j.amjcard.2009.12.046

Mohanty P, et al. Stiff left atrial syndrome after catheter ablation for atrial fibrillation: clinical characterization, prevalence, and predictors [published correction appears in Heart Rhythm. 2011 Nov;8(11):1828]. Heart Rhythm. 2011;8(9):1364‐1371. doi:10.1016/j.hrthm.2011.02.026

Santangeli P, Zado ES, Garcia FC, et al. Lack of prognostic value of atrial arrhythmia inducibility and change in inducibility status after catheter ablation of atrial fibrillation. Heart Rhythm. 2018;15(5):660‐665. doi:10.1016/j.hrthm.2017.10.023

Lee KN, Roh SY, Baek YS, et al. Long-Term Clinical Comparison of Procedural End Points After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation: Elimination of Nonpulmonary Vein Triggers Versus Noninducibility. Circ Arrhythm Electrophysiol. 2018;11(2):e005019. doi:10.1161/CIRCEP.117.005019

Tran VN, Kusa S, Smietana J, et al. The relationship between oesophageal heating during left atrial posterior wall ablation and the durability of pulmonary vein isolation. Europace. 2017;19(10):1664‐1669. doi:10.1093/europace/euw232

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Published

2020-05-26

How to Cite

Smietana, J., & Santangeli, P. (2020). Long-standing Persistent Atrial Fibrillation Ablation: How do You Perform it?. JOURNAL OF CARDIAC ARRHYTHMIAS, 33(2), 96–105. Retrieved from https://www.jca.org.br/jca/article/view/3399