Electrogram Fractionation-Guided Ablation in the Left Atrium Decreases the Frequency of Activation in the Pulmonary Veins and Leads to Atrial Fibrillation Termination: Pulmonary Vein Modulation Rather Than Isolation

Julien Seitz; Clement Bars; Ange Ferracci; Alexandre Maluski; Guillaume Penaranda; Guillaume Theodore; Jacques Faure; Michel Bremondy; Laurence Curel; Sylvain Beurtheret; Uma M R Avula; Jerome Kalifa; Andre Pisapia

doi:10.1016/j.jacep.2016.04.003

Electrogram Fractionation-Guided Ablation in the Left Atrium Decreases the Frequency of Activation in the Pulmonary Veins and Leads to Atrial Fibrillation Termination: Pulmonary Vein Modulation Rather Than Isolation

JACC Clin Electrophysiol. 2016 Nov;2(6):732-742. doi: 10.1016/j.jacep.2016.04.003. Epub 2016 Jun 1.

Affiliations

¹ Cardiology Rhythmology Department, Saint Joseph Hospital, Marseille, France. Electronic address: jseitz@hopital-saint-joseph.fr.
² Cardiology Rhythmology Department, Saint Joseph Hospital, Marseille, France; Cardiology Rhythmology Department, Private Hospital Institute Mutualiste Montsouris, Paris, France.
³ Cardiology Rhythmology Department, Saint Joseph Hospital, Marseille, France.
⁴ Statistics Department, Alphabio Laboratory, Hôpital Européen Marseille, Marseille, France.
⁵ Cardiology Rhythmology Department, Nice University Hospital, Nice, France.
⁶ Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA.

PMID: 29759752
DOI: 10.1016/j.jacep.2016.04.003

Abstract

Objectives: This study sought to evaluate the impact of a complex fractionated atrial electrogram (CFAE)-guided ablation strategy on atrial fibrillation (AF) dynamics in patients with persistent AF.

Background: It is still unclear whether complete pulmonary vein isolation (PVI) is required or if the ablation of well-delineated pulmonary vein (PV) subregions could achieve similar outcomes in persistent AF.

Methods: CFAE-guided ablations were performed in 76 patients (65.2 ± 10 years of age) with persistent AF. In 47 patients, we measured mean PVs and left atrial appendage (LAA) cycle length (CL) values (PV-CL and LAA-CL), before ablation and before AF termination. We defined "active" PVs as PV-CL ≤ LAA-CL, "rapid fires" as PV-CL ≤80% of LAA-CL, and "PV-LAA CL gradient" as a significant CL difference between the 2 regions.

Results: AF termination (sinus rhythm [SR] or atrial tachycardia [AT] conversion) occurred in 92% and SR conversion in 75%. The radiofrequency time for AF termination and total radiofrequency time were 26 ± 25 min and 61.1 ± 21.6 min, respectively. Thirty of 47 patients had active PV (with 19 PV "rapid fires"). Ablation significantly increased median CL, both at PVs and LAA from 188 ms (interquartile range [IQR]: 161 to 210 ms) to 227.5 ms (IQR: 200 to 256 ms) (p < 0.0001) and from 197 ms (IQR: 168 to 220 ms) to 224 ms (IQR: 193 to 250 ms) (p < 0001), respectively. After ablation, PV-LAA CL gradients were withdrawn and all PV "rapid fires" were extinguished (without PVI). After 17.2 ± 10 months of follow-up and 1.61 ± 0.75 procedures, 86.3% and 73% of the patients were free from AF and from any arrhythmia (AF/AT), respectively.

Conclusions: CFAE-guided ablation leads to a large decrease in PV frequency of activation, preceding AF termination. A PV modulation approach, rather than complete PVI, may be preferable for persistent AF.

Keywords: atrial fibrillation; catheter ablation; complex fractionated atrial electrogram; pulmonary vein activity; substrate.