Abstract
BackgroundFirst pass pulmonary vein isolation (PVI) is associated with durable isolation and reduced recurrence of atrial fibrillation (AF).ObjectiveWe sought to investigate the relationship between left atrial electrogram voltage using multielectrode fast automated mapping (ME-FAM) and first pass isolation with radiofrequency ablation.MethodsWe included consecutive patients (pts) undergoing first time ablation for paroxysmal AF (pAF), and compared the voltage characteristics between patients with and without first pass isolation. Left atrium (LA) adjacent to PVs was divided into 6 regions, and mean voltages obtained with ME-FAM (Pentaray, Biosense Webster) in each region and compared. LA electrograms with marked low voltage (<0.5 mV) were identified and the voltage characteristics at the site of difficult isolation was compared to the voltage in adjacent region.ResultsTwenty consecutive patients (10 with first pass and 10 without) with a mean age of 63.3 ± 6.2 years, 65% males, were studied. Difficult isolation occurred on the right PVs in eight pts and left PVs in three pts. The mean voltage in pts without first pass isolation was lower in all 6 regions; posterior wall (1.93 ± 1.46 versus 2.99 ± 2.19; p < 0.001), roof (1.83 ± 2.29 versus 2.47 ± 1.99; p < 0.001), LA-LPV posterior (1.85 ± 3.09 versus 2.99 ± 2.19, p < 0.001), LA-LPV ridge (1.42 ± 1.04 versus 1.91 ± 1.61; p < 0.001), LA-RPV posterior (1.51 ± 1.11 versus 2.30 ± 1.77, p < 0.001) and LA-RPV septum (1.55 ± 1.23 versus 2.31 ± 1.40, p < 0.001). Patients without first pass isolation also had a larger percentage of signal with an amplitude of <0.5 mV for each of the six regions (12.8% versus 7.5%). In addition, the mean voltage at the site of difficult isolation was lower at 8 out of 11 sites compared to mean voltage for remaining electrograms in that region.ConclusionIn patients undergoing PVI for paroxysmal AF, failure in first pass isolation was associated with lower global LA voltage, more marked low amplitude signal (<0.5 mV) and lower local signal voltage at the site with difficult isolation. The results suggest that a greater degree of global and segmental fibrosis may play a role in ease of PV isolation with radiofrequency energy.
Highlights
Pulmonary vein isolation (PVI) with catheter ablation is an effective therapy for paroxysmal atrial fibrillation and is recommended for drug refractory symptomatic pAF (January et al, 2014)
20 patients (10 in each group; Group 1: First pass isolation and Group 2: No first pass isolation) had detailed multielectrode fast automated mapping (ME-FAM) obtained during sinus rhythm over all six regions and were included in the analysis
The mean age was greater in patients with first pass isolation (65.4 years in group 1 versus 61.2 years in group 2; p = 0.026)
Summary
Pulmonary vein isolation (PVI) with catheter ablation is an effective therapy for paroxysmal atrial fibrillation (pAF) and is recommended for drug refractory symptomatic pAF (January et al, 2014). Durability of PVI is important and reconnection of previously isolated pulmonary veins (PVs) is associated with higher risk of recurrent AF (Callans et al, 2004; Lemola et al, 2004; Nilsson et al, 2006; Natale et al, 2010; January et al, 2014). First pass isolation during initial catheter ablation has been shown to be associated with durable PVI and a lower risk of recurrence (Sandorfi et al, 2018; Yamaguchi et al, 2020). We aimed to determine the relationship between the left atrial bipolar electrogram voltage obtained with multielectrode fast automated mapping (ME-FAM) in sinus rhythm and first pass isolation with radiofrequency catheter ablation. First pass pulmonary vein isolation (PVI) is associated with durable isolation and reduced recurrence of atrial fibrillation (AF)
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