Abstract
Catheter ablation of long-standing persistent atrial fibrillation (LSPAF) presents unique challenges and the lack of large body of evidence surrounding management makes for disagreement and different approaches for treatment. Outlined is a case example that offers a comprehensive approach to ablation in patients with LSPAF that consists of risk factor management, an ablation strategy, a rigorous trigger protocol and follow-up rhythm monitoring. The case presented highlights management of this difficult population as best guided by current evidence and our experience. Ablation treatment and management strategies will continue to evolve with further randomized data and the advent of improved ablation technologies.
Highlights
Outcomes of catheter ablation in patients with long-standing persistent atrial fibrillation (LSPAF), defined as continuous atrial fibrillation (AF) > 12 months duration, have worse long-term arrhythmia free survival compared with ablation of paroxysmal atrial fibrillation.For both pAF and LSPAF,empiric pulmonary vein isolation (PVI) is the foundation of catheter ablation as pulmonary vein (PV) triggers have a similar prevalence in both entities
The etiology for recurrence in the above case was secondary to reconnection of the posterior wall and coronary sinus, with freedom from AF achieved after repeat isolation and no further evidence of non-PV triggers
Catheter ablation of LSPAF presents unique challenges and the lack of large body of robust evidence surrounding management makes for disagreement and different approaches for treatment
Summary
Outcomes of catheter ablation in patients with long-standing persistent atrial fibrillation (LSPAF), defined as continuous atrial fibrillation (AF) > 12 months duration, have worse long-term arrhythmia free survival compared with ablation of paroxysmal atrial fibrillation (pAF).For both pAF and LSPAF,empiric pulmonary vein isolation (PVI) is the foundation of catheter ablation as pulmonary vein (PV) triggers have a similar prevalence in both entities. Our ablation approach consists of empiric wide antral circumferential isolation of the PVs in addition to empiric posterior wall isolation (PWI) This is followed by a rigorous trigger protocol which includes infusion of high doses of isoproterenol with and without atrial burst pacing with the aim of identifying and safely isolating or eliminating all potential AF triggers. In case of persistent posterior wall connection, additional segmental ablation is performed targeting the earliest sites within the posterior wall in order to achieve isolation with bidirectional block The latter is verified by careful remapping of the posterior wall demonstrating lack of EGMs (entrance block) and pacing at different sites at 10 and 50 mA output to demonstrate exit block. The posterior wall and coronary sinus were reisolated with segmental ablation using an open-irrigated catheter with contact force sensing (Tacticath SE, St. Jude Medical, St. Paul, MN) using the same high-power settings detailed above (Fig. 5). The patient has remained in sinus rhythm off antiarrhythmic medications for > 1 year without evidence of recurrence on his implantable loop recorder
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