Selective segmental ostial ablation and circumferential pulmonary veins ablation. Results of an individualized strategy to cure refractory atrial fibrillation

Abstract

Previous studies have analyzed the efficacy of atrial fibrillation (AF) ablation in series of consecutive patients or comparing methods in a randomized way, without taking account individual patient characteristics. The purpose of this study was to evaluate the results of a strategy based on selecting the ablation method according to patient clinical features in drug-refractory paroxysmal or persistent AF. Patients with left atrial diameter < or =40 mm and runs of atrial tachycardia of more than ten beats during Holter recording were selected for selective segmental ostial ablation (SSOA) in order to disconnect only those pulmonary veins with electrical potentials. The remaining patients underwent circumferential pulmonary veins ablation (CPVA) to modify left atrial substrate by extensive linear lesions. A group of 131 consecutive patients were included. Mean follow-up was 21.5 +/- 15.2 months. In paroxysmal AF, 44 and 55 patients were selected for SSOA and CPVA, respectively, and the efficacy of the procedure was similar in the two groups (77 vs 74%; log-rank test p = NS). In persistent AF, 6 and 26 patients underwent SSOA and CPVA, respectively, and greater efficacy was observed in the second group (17 vs 65%; log-rank test p = 0.004). Selecting the ablation method according to patient characteristics achieved good results and reduced the overall amount of ablated atrial tissue in patients with paroxysmal AF. However, in persistent AF the SSOA technique showed very limited efficacy despite the previous patient selection and a CPVA-like procedure may be the appropriate choice in all cases.