A prospective randomized study comparing isolation of the arrhythmogenic vein versus all veins in paroxysmal atrial fibrillation

Abstract

Background: Ablation procedures in patients with paroxysmal atrial fibrillation (PAF) includes isolation of all pulmonary veins (PVs). We hypothesized that an approach using an algorithm to detect arrhythmogenic PVs (aPVs) might lead to shorter procedure duration (PD) and fewer proarrhythmic effects (PE).

Hypothesis: Isolation of the aPVs only leads to a reduced PD, reduced PEs, and fewer adverse events, with a success rate comparable to the standard all-PV approach.

Methods: In this prospective trial, 207 patients with PAF were randomized to undergo isolation of the aPV (AG group, n = 105) or isolation of all PVs (VG group, n = 102). The aPV was identified by atrial fibrillation (AF) induction, focal discharge, or short local PV decremental conduction during PV pacing. Patients were followed with repetitive 7-day Holter electrocardiograms (ECGs) after 3, 6, and 12 months in our arrhythmia clinic.

Results: In 97% of patients, at least 1 aPV was identified (mean, 2.1). PD did not differ significantly (152.3 ± 57.1 minutes vs 162 ± 68 minutes, P = 0.27) between the groups, but the number of radiofrequency (RF) applications and fluoroscopy time (FT) and dose were significantly lower in the AG group than in the VG group. The occurrence of PE (new-onset atrial tachycardia) and adverse events (AE) did not differ between the 2 groups (P = 0.1). Sinus rhythm off antiarrhythmic medication (documented on 7-day Holter ECGs) 12 months after a single procedure was achieved in 53% in the AG group and 59% in the VG group (P = 0.51).

Conclusions: Isolation of the aPVs detected by a straightforward algorithm leads to similar success rates compared to a standard all-PV approach with regard to PD, AE, or PE and is associated with less RF and a shorter FT.

Trial registration: ClinicalTrials.gov NCT00605748.

Figure 1

Programmed stimulation in the left inferior pulmonary vein (LIPV) with S1 400 ms and 1 extra stimuli with 150 ms inducing atrial fibrillation (AF), with a cycle length (CL) of 156 ms in the LIPV and AF with a slower CL in the left atrium. Abbreviations: CS, signal of coronary sinus catheter; Map, signal of ablation catheter; Orb, signal of circular mapping catheter in the pulmonary veins; RIPV, right inferior pulmonary vein.

Figure 2

Anatomical distribution of all arrhythmogenic pulmonary veins (PVs) identified with our pacing algorithm. A total of 2.1 ± 1.0 arrhythmogenic PVs per patient were detected. Abbreviations: LIPV, left inferior PV; LSPV, left superior PV; RIPV right inferior PV; RSPV, right surperior PV.

Figure 3

Results of pacing manoeuvers. Atrial fibrillation (AF) induction and detection of pulmonary vein (PV) triggers were achieved with programmed stimulation inside the PVs in 71% of patients and after orciprenaline in 11% of patients. The arrhythmogenic PV was detected because of increased decremental conduction in 15% of patients, and in 3% of patients no arrhythmogenic PV was found.