Optimal observation time after completion of circumferential pulmonary vein isolation for atrial fibrillation to prevent chronic pulmonary vein reconnections

Blanking period antiarrhythmic drugs after catheter ablation for atrial fibrillation: a meta-analysis of randomized controlled trials

Background

Antiarrhythmic drugs (AADs) are frequently prescribed following catheter ablation (CA) for atrial fibrillation (AF). However, to date, there is a lack of large-scale, multicenter controlled studies that have confirmed the efficacy of AADs in reducing the incidence of late recurrence of AF after CA. Furthermore, the optimal duration of short-term use of AADs after CA remains a controversial topic.

Methods

PubMed, Embase, Cochrane Library, CNKI, and ClinicalTrials.gov were searched until April 25, 2022. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of blanking period AADs in predicting both early and late recurrence of AF. In addition, Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence in this meta-analysis.

Results

12 RCTs with 3,625 patients were included in this meta-analysis. Short-term use of AADs after AF ablation reduced the risk of early recurrence of AF compared with the no-AADs group. In the subgroup analysis of AADs use time, it was found that only using AADs for more than 2 months can reduce the early recurrence of AF after CA. However, when compared with the no-AADs group, short-term use of AADs after CA did not reduce the incidence of late recurrence of AF.

Conclusions

Short-term use of AADs (more than 2 months) can reduce the early recurrence but not the late recurrence of AF after CA.

Sequential versus optimized pulmonary vein isolation for paroxysmal atrial fibrillation: a pilot study

PURPOSE

We aimed to investigate whether the sequence of wide circumferential pulmonary vein isolation (PVI) ablation had an effect on the acute reconnection or long-term effectiveness in patients with paroxysmal atrial fibrillation (AF).

METHODS

One hundred consecutive paroxysmal AF patients, who were scheduled to accept PVI, were enrolled and randomized into two groups: (1) optimized group. Lesions were first applied to the anterior/posterior carina and the ridge between the left atrial (LA) appendage and the left pulmonary vein (PV). Then both circles were closed with continuous lesions. (2) Sequential group-continuous circular lesions were created counter-clockwise and started from the site of 6 o'clock. The primary endpoint was the freedom from non-blanking period recurrence of any atrial tachyarrhythmias lasting for 30 s or longer during the 1-year follow-up period after a single procedure. The secondary endpoint included safety endpoints, LA dwelling time, and fluoroscopy time/dose.

RESULTS

Forty-nine patients in the optimized group and 48 patients in the sequential group were available for analysis. There was no difference between the AF-free rate of the optimized group and the sequential group (75.5% vs. 72.9%, p = 0.7715). Cox regression analysis found that acute reconnection had the potential to predict long-term recurrence at 1 year (Risk ratio 2.175, p = 0.0818). Both groups had similar safety endpoints, LA dwelling time, and fluoroscopy time/dose.

CONCLUSIONS

Adjusting the ablation sequence of PVI by ablating the anterior/posterior carina and the ridge between the left PV and the LA appendage first did not improve 1-year AF-free rate for paroxysmal AF.

Localization of Residual Conduction Gaps After Wide Antral Circumferential Ablation of Pulmonary Veins

Ablation of atrial fibrillation (AF) is the cornerstone therapy for patients with symptomatic AF resistant to anti-arrhythmic drugs or as first-line therapy, and is based on permanent pulmonary vein (PV) isolation. The presence of a conduction gap in a wide antral circumferential ablation lesion around PVs is often sufficient to transform an initially successful ablation into a procedural failure, thus necessitating a redo intervention. The strategy during a redo procedure is based on the detection and ablation of the reconnection gap. Finding gaps is often simple, but also sometimes challenging, because gaps may be difficult to detect, resulting in unnecessary radiofrequency delivery. The present review aimed to describe the various techniques published thus far to detect residual reconnections along the encircling ablation lines around PVs, to help electrophysiologists to detect and ablate reconnection gaps.

Predictors of chronic pulmonary vein reconnections after contact force-guided ablation: importance of completing electrical isolation with circumferential lines and creating sufficient ablation lesion densities

PURPOSE

We aimed to identify the predictors of chronic pulmonary vein reconnections (CPVRs) after contact force (CF)-guided circumferential PV isolation (CPVI) of atrial fibrillation (AF).

METHODS

Forty-nine consecutive patients undergoing second ablation procedures for recurrent AF after CF-guided ablation were retrospectively studied. The CPVI was performed by point-by-point ablation with a target CF of 15-20 g. The incidence of CPVRs was evaluated along the right- and left-sided anterior and posterior CPVI regions (Ant-RPVs, Post-RPVs, Ant-LPVs, and Post-LPVs).

RESULTS

CPVRs were observed in 30.6, 22.4, 20.4, and 32.7 % of patients along the Ant-RPVs, Post-RPVs, Ant-LPVs, and Post-LPVs, respectively (P = 0.436). In the multivariate logistic analyses, completing a left atrium-PV conduction block with touch-up ablation inside the initially estimated CPVI lines (Ant-RPVs, Post-RPVs, Ant-LPVs, Post-LPVs; odds ratio [OR] 5.747, 15.000, 207.619, 7.940; P = 0.032, 0.004, 0.034, 0.021) and region length (Post-LPVs; OR 3.183, P = 0.027) were positive predictors of CPVRs, while the mean CF (Ant-RPVs; OR 0.861, P = 0.045) and number of radiofrequency applications per unit length (Ant-LPVs, Post-LPVs; OR 0.038, 0.122; P = 0.034, 0.029) were negative predictors. At optimal cutoffs of 5.8 cm for the region length, 14.2 g for the mean CF, and 1.97/cm (Ant-LPVs) and 2.01/cm (Post-LPVs) for the radiofrequency application density, the sensitivity and specificity were 93.8 and 63.6 %, 60.0 and 76.5 %, 90.0 and 64.1 %, and 75.0 and 63.6 %, respectively.

CONCLUSIONS

Completing PVI with circumferential lines without touch-up ablation and creating a sufficient density of radiofrequency ablation lesions on the lines with a sufficient CF may be necessary to prevent CPVRs after a CF-guided CPVI.

Recurrent Atrial Fibrillation After Catheter Ablation: Considerations For Repeat Ablation And Strategies To Optimize Success

Recurrent AF after catheter ablation occurs in at least 20 to 40% of patients. Repeat ablation is primarily considered for those with symptomatic AF recurrences (often drug-refactory) occurring at least 3 months or more post-ablation. Pulmonary vein reconnection is almost universally encountered, and repeat isolation of electrically connected pulmonary veins should be the primary ablation strategy. Beyond repeat PVI and possible ablation of non-PV triggers, there is little to no evidence that additional substrate modification improves outcomes. In addition to repeat ablation, it is critical to address and treat comorbid conditions which increase arrhythmia risk post-ablation. Specifically, obesity, hypertension, and sleep-disordered breathing should be targeted and modified to increase the likelihood of success.

Pharmacological Tests in Atrial Fibrillation Ablation

The invasive management of atrial fibrillation (AF) has been considerably changed by the identification of major sites of AF initiation and/or maintenance within the pulmonary vein antra. Percutaneous catheter ablation of these targets has become the standard of care for sustained maintenance of sinus rhythm. Long-term failure of ablation is related to an inability to create a durable transmural lesion or to identify all of the non-pulmonary vein arrhythmia triggers. Pharmacological challenges during catheter ablation have been suggested to improve outcomes in both paroxysmal and persistent AF. Herein we review the mechanism and evidence for the use of pharmacological adjuncts during the catheter ablation of AF.

Is pulmonary vein isolation still the cornerstone in atrial fibrillation ablation?

Radiofrequency catheter ablation for atrial fibrillation (AF) has become a frequently used therapy after failure of at least one antiarrhythmic drug. The cornerstone of AF ablation has been durable pulmonary vein isolation. However, understanding the positive and negative outcomes of catheter ablation of AF is severely limited by diverse ablation methodologies that do not seem to result in durable pulmonary vein isolation. Without durable pulmonary isolation ablation, it is unclear if ablation strategies need to be modified to include extrapulmonary vein ablation targets in combination with pulmonary vein isolation or alone to improve long-term procedural success rates. The marked discrepancy between AF ablation procedure success rates and actual long-term pulmonary vein isolation rates does suggest that targeting other mechanisms can be considered to achieve similar or better results when compared to pulmonary vein isolation alone.