Ablation for Persistent Atrial Fibrillation-Is There a Role for More Than PVI?

Overview

Journal Curr Treat Options Cardiovasc Med

Specialty Cardiology & Vascular Diseases

Date 2016 Feb 15

PMID 26874703

Citations 4

Authors

Jason M Lappe

Michael J Cutler

John D Day

T Jared Bunch

Affiliations

Soon will be listed here.

Abstract

Persistent atrial fibrillation (AF) is a prevalent condition that can be difficult to treat medically, and an ablation strategy is often sought. Currently, the cornerstone of AF ablation strategies is pulmonary vein isolation (PVI). Unfortunately, the single procedure success rates are limited, particularly when long-term outcomes (>1 year) are considered. As a result, the most recent consensus statement recommends that in patients with persistent AF a more extensive ablation be considered. Many additive procedural approaches to PVI have been investigated. These include electrical compartmentalization of the atria with linear lesions (LLs), ablation of complex fractionated atrial electrograms (CFAEs), ablation of the dominant frequency (DF) signals, and focal impulse and rotor modulation (FIRM) ablation. Each of these approaches has demonstrated degrees of additive success when performed with a PVI in patients with persistent AF. This review provides an in-depth discussion of these techniques, their successes in treating persistent AF, and their shortcomings.

Citing Articles

Effect of electrical posterior wall isolation on left atrial mechanical function.

Ellis E, Weaver C, Loffler A, Trivedi A J Interv Card Electrophysiol. 2025; .

PMID: 39946035 DOI: 10.1007/s10840-025-02008-9.

Integrated Management of Persistent Atrial Fibrillation.

Yue X, Zhou L, Zhao C Biomedicines. 2025; 13(1).

PMID: 39857675 PMC: 11760448. DOI: 10.3390/biomedicines13010091.

Rationale and Outcomes of Cryoballoon Ablation of the Left Atrial Posterior Wall in Conjunction with Pulmonary Vein Isolation.

Aryana A J Innov Card Rhythm Manag. 2021; 12(8):4633-4646.

PMID: 34476116 PMC: 8384303. DOI: 10.19102/icrm.2021.120801.

Left atrial posterior wall isolation in conjunction with pulmonary vein isolation using cryoballoon for treatment of persistent atrial fibrillation (PIVoTAL): study rationale and design.

Aryana A, Pujara D, Allen S, Baker J, Espinosa M, Buch E J Interv Card Electrophysiol. 2020; 62(1):187-198.

PMID: 33009645 PMC: 8210744. DOI: 10.1007/s10840-020-00885-w.

The association between left atrial stiffness and low-voltage areas of left atrium in patients with atrial fibrillation.

Kishima H, Mine T, Fukuhara E, Ashida K, Ishihara M Heart Vessels. 2019; 34(11):1830-1838.

PMID: 31049675 DOI: 10.1007/s00380-019-01423-z.

References

Luise Estner H, Hessling G, Ndrepepa G, Wu J, Reents T, Fichtner S . Electrogram-guided substrate ablation with or without pulmonary vein isolation in patients with persistent atrial fibrillation. Europace. 2008; 10(11):1281-7. DOI: 10.1093/europace/eun244. View

Brooks A, Stiles M, Laborderie J, Lau D, Kuklik P, Shipp N . Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review. Heart Rhythm. 2010; 7(6):835-46. DOI: 10.1016/j.hrthm.2010.01.017. View

Hocini M, Jais P, Sanders P, Takahashi Y, Rotter M, Rostock T . Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation: a prospective randomized study. Circulation. 2005; 112(24):3688-96. DOI: 10.1161/CIRCULATIONAHA.105.541052. View

Patterson E, Po S, Scherlag B, Lazzara R . Triggered firing in pulmonary veins initiated by in vitro autonomic nerve stimulation. Heart Rhythm. 2005; 2(6):624-31. DOI: 10.1016/j.hrthm.2005.02.012. View

Atienza F, Almendral J, Jalife J, Zlochiver S, Ploutz-Snyder R, Torrecilla E . Real-time dominant frequency mapping and ablation of dominant frequency sites in atrial fibrillation with left-to-right frequency gradients predicts long-term maintenance of sinus rhythm. Heart Rhythm. 2009; 6(1):33-40. PMC: 2867332. DOI: 10.1016/j.hrthm.2008.10.024. View

January C, Samuel Wann L, Alpert J, Calkins H, Cigarroa J, Cleveland Jr J . 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014; 64(21):e1-76. DOI: 10.1016/j.jacc.2014.03.022. View

Jais P, Haissaguerre M, Shah D, Chouairi S, Clementy J . Regional disparities of endocardial atrial activation in paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 1996; 19(11 Pt 2):1998-2003. DOI: 10.1111/j.1540-8159.1996.tb03269.x. View

Chen H, Wen J, Wu S, Liu J . Catheter ablation for paroxysmal and persistent atrial fibrillation. Cochrane Database Syst Rev. 2012; (4):CD007101. PMC: 11374149. DOI: 10.1002/14651858.CD007101.pub2. View

Zheng L, Yao Y, Zhang S, Chen W, Zhang K, Wang F . Organized left atrial tachyarrhythmia during stepwise linear ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2008; 20(5):499-506. DOI: 10.1111/j.1540-8167.2008.01371.x. View

10.

Arenal A, Datino T, Atea L, Atienza F, Gonzalez-Torrecilla E, Almendral J . Dominant frequency differences in atrial fibrillation patients with and without left ventricular systolic dysfunction. Europace. 2009; 11(4):450-7. DOI: 10.1093/europace/eup053. View

11.

Haissaguerre M, Hocini M, Sanders P, Sacher F, Rotter M, Takahashi Y . Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol. 2005; 16(11):1138-47. DOI: 10.1111/j.1540-8167.2005.00308.x. View

12.

Wilber D, Pappone C, Neuzil P, de Paola A, Marchlinski F, Natale A . Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA. 2010; 303(4):333-40. DOI: 10.1001/jama.2009.2029. View

13.

Katritsis D, Pokushalov E, Romanov A, Giazitzoglou E, Siontis G, Po S . Autonomic denervation added to pulmonary vein isolation for paroxysmal atrial fibrillation: a randomized clinical trial. J Am Coll Cardiol. 2013; 62(24):2318-25. DOI: 10.1016/j.jacc.2013.06.053. View

14.

Kumagai K, Sakamoto T, Nakamura K, Nishiuchi S, Hayano M, Hayashi T . Combined dominant frequency and complex fractionated atrial electrogram ablation after circumferential pulmonary vein isolation of atrial fibrillation. J Cardiovasc Electrophysiol. 2013; 24(9):975-83. DOI: 10.1111/jce.12166. View

15.

Hocini M, Sanders P, Jais P, Hsu L, Weerasoriya R, Scavee C . Prevalence of pulmonary vein disconnection after anatomical ablation for atrial fibrillation: consequences of wide atrial encircling of the pulmonary veins. Eur Heart J. 2005; 26(7):696-704. DOI: 10.1093/eurheartj/ehi096. View

16.

Ernst S, Ouyang F, Lober F, Antz M, Kuck K . Catheter-induced linear lesions in the left atrium in patients with atrial fibrillation: an electroanatomic study. J Am Coll Cardiol. 2003; 42(7):1271-82. DOI: 10.1016/s0735-1097(03)00940-9. View

17.

Oral H, Chugh A, Yoshida K, Sarrazin J, Kuhne M, Crawford T . A randomized assessment of the incremental role of ablation of complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation. J Am Coll Cardiol. 2009; 53(9):782-9. DOI: 10.1016/j.jacc.2008.10.054. View

18.

Dixit S, Marchlinski F, Lin D, Callans D, Bala R, Riley M . Randomized ablation strategies for the treatment of persistent atrial fibrillation: RASTA study. Circ Arrhythm Electrophysiol. 2011; 5(2):287-94. DOI: 10.1161/CIRCEP.111.966226. View

19.

Narayan S, Wright M, Derval N, Jadidi A, Forclaz A, Nault I . Classifying fractionated electrograms in human atrial fibrillation using monophasic action potentials and activation mapping: evidence for localized drivers, rate acceleration, and nonlocal signal etiologies. Heart Rhythm. 2010; 8(2):244-53. PMC: 3127735. DOI: 10.1016/j.hrthm.2010.10.020. View

20.

Jacobs V, May H, Bair T, Crandall B, Cutler M, Day J . The impact of risk score (CHADS2 versus CHA2DS2-VASc) on long-term outcomes after atrial fibrillation ablation. Heart Rhythm. 2014; 12(4):681-6. DOI: 10.1016/j.hrthm.2014.12.034. View