Circumferential pulmonary vein ablation for atrial fibrillation: back to the future?

Abstract

antrum within the encircling lesions, elimination of anchor points of high frequency drivers, atrial debulking, and possibly ablation of ganglionated plexi within the targeted encircling lesions. As the role of PV antrum in AF is better understood, antral PV isolation has been widely performed as an effective ablation strategy to eliminate AF. It is within this context that we should evaluate the contribution by Arya et al. 7 in the current issue of the Journal. The authors report their experience in 674 consecutive patients, 85% of whom had paroxysmal AF, undergoing CPVA using a steerable sheath during 2005‐2007. An irrigated-tip ablation catheter was used with a maximum power of 25 W near the oesophagus and 40‐50 W elsewhere in the left atrium. The sole procedural endpoint was voltage attenuation along the circumferential lines around each set of PVs in patients with paroxysmal AF. Pulmonary vein isolation was not an endpoint of the procedure, but was achieved in 38% of patients. In a minority of patients with persistent AF, linear ablation along the roof and mitral isthmus was performed without confirmation of conduction block. Antiarrhythmic agents (flecainide or amiodarone) were used in 45% and 21% of patients for the first 3 and 6 months, respectively, and were discontinued after 6 months in all patients. Clinical outcome was based on symptoms or the presence of AF or AT on serial 7-day Holter recordings performed at 3, 6, and 12 months after the ablation procedure. The procedure and fluoroscopic times were approximately, 3 h, and 24 min, respectively. After a single-ablation procedure using a steerable sheath, 76% of patients were free from atrial arrhythmias during a 7-day monitoring period at 12 months. Approximately 50% of patients experienced early recurrence, which was due solely due to AT in about one-third of the patients. Early recurrence and a LA diameter .5 cm were associated with arrhythmia recurrence during follow-up. The clinical efficacy was similar among patients with paroxysmal or persistent AF. Six patients experienced pericardial tamponade, one of whom required surgery.