Incidence, characteristics, and outcome of left atrial tachycardias after circumferential antral ablation of atrial fibrillation

Abstract

Antral pulmonary vein isolation (PVI) for treatment of atrial fibrillation may induce left atrial tachycardias (ATs). To determine the prevalence, time course of occurrence, mechanisms, and correlation with the electrocardiogram as well as the outcome of ablation of these tachycardias. Out of the 839 patients who underwent circumferential antral radiofrequency PVI guided by a circumferential pulmonary vein catheter at our institution between February 2005 and April 2011, 35 patients (4%) developed AT during follow-up. Six patients with left AT and a previous PVI at other institutions were also included. Of these 41 patients (26 men, 63%; age 59 ± 10 years), 26 (63%) had underlying paroxysmal atrial fibrillation and 15 (37%) had persistent atrial fibrillation. AT ablation was performed 47 ± 60 weeks after initial PVI, within the first 3 months in 16 patients (39%). The tachycardia mechanism was focal in 15 patients (37%), macroreentry in 25 patients (61%), and undetermined in 1 (2%). Focal tachycardias had an isoelectric line between distinct P waves in 13 of the 15 patients (87%), while only 4 (16%) with a macroreentrant mechanism had an isoelectric line (P <.001). Although difficult to measure, a P-wave width of >140 ms had the highest sensitivity and specificity to identify macroreentrant mechanism. Ablation was acutely successful in 32 patients (78%) and not successful in 4 (10%). In 5 patients, success could not be determined as the tachycardia terminated or degenerated during mapping. During a mean follow-up of 31 ± 17 months, 11 patients (27%; n = 9 [82%] with macroreentry) underwent repeat ablation procedure for AT. Eight patients had true recurrence, for example, the same AT, and 3 patients had a second mechanism of AT. With the use of an identical ablation protocol, it was found that approximately 4% of the patients developed AT after mere circumferential antral PVI. The majority of ATs developed within a few months after ablation but occurred as late as several years after the initial PVI. Macroreentry was more frequent than a focal mechanism. Broad P waves and isoelectric lines between P waves help to distinguish a focal mechanism from a macroreentrant mechanism. Ablation has a high acute success rate, and AT recurrence occurs predominantly in macroreentrant AT.