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Review
. 2015 Apr-Jun;11(2):71-5.
doi: 10.14797/mdcj-11-2-71.

Catheter Ablation of Paroxysmal Atrial Fibrillation: Have We Achieved Cure with Pulmonary Vein Isolation?

Pasquale Santangeli  1 , David Lin  1
Affiliations
Review

Catheter Ablation of Paroxysmal Atrial Fibrillation: Have We Achieved Cure with Pulmonary Vein Isolation?

Pasquale Santangeli et al. Methodist Debakey Cardiovasc J. 2015 Apr-Jun.

Abstract

Pulmonary vein isolation (PVI) is the cornerstone of current ablation techniques to eliminate atrial fibrillation (AF), with the greatest efficacy as a stand-alone procedure in patients with paroxysmal AF. Over the years, techniques for PVI have undergone a profound evolution, and current guidelines recommend PVI with confirmation of electrical isolation. Despite significant efforts, PV reconnection is still the rule in patients experiencing post-ablation arrhythmia recurrence. In recent years, use of general anesthesia with or without jet ventilation, open-irrigated ablation catheters, and steerable sheaths have been demonstrated to increase the safety and efficacy of PVI, reducing the rate of PV reconnection over follow-up. The widespread clinical availability of ablation catheters with real-time contact force information will likely further improve the effectiveness and safety of PVI. In a small but definite subset of patients, post-ablation recurrent arrhythmia is due to non-PV triggers, which should be eliminated in order to improve success. Typically, non-PV triggers cluster in specific regions such as the coronary sinus, the inferior mitral annulus, the interatrial septum, the left atrial appendage, the Eustachian ridge, the crista terminalis region, the superior vena cava, and the ligament of Marshall. Focal ablation targeting the origin of the trigger is recommended in most cases. Empirical non-PV ablation targeting the putative substrate responsible for AF maintenance with ablation lines and/or elimination of complex fractionated electrograms has not been shown to improve success compared to PVI alone. Similarly, the role of novel substrate-based ablation approaches targeting putative localized sources of AF (e.g., rotors) identified by computational mapping techniques is unclear, as they have never been compared to PVI and non-PV trigger ablation in an adequately designed randomized trial. This review highlights PVI techniques and outcomes in treating recurrent drug-refractory AF and discusses the potential role of additional non-PV ablation.

Keywords: atrial fibrillation; catheter ablation; pulmonary vein isolation.

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Figures

None
P. Santangeli, M.D.
None
D. Lin, M.D.
Figure 1.
Figure 1.
Combined evidence that wide antral pulmonary vein isolation improves long-term arrhythmia-free survival compared to ostial pulmonary vein isolation. From Proietti et al. with permission.
Figure 2.
Figure 2.
Prevalence of pulmonary vein reconnection in patients undergoing repeat catheter ablation procedures.
Figure 3.
Figure 3.
Outcomes of pulmonary vein isolation with the SmartTouch (Biosense Webster, Diamond Bar, CA) force-sensing catheter. Data from Natale et al.
See this image and copyright information in PMC

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