Double Lasso Technique Research Articles

Ten-Year Clinical Outcome After Circumferential Pulmonary Vein Isolation Utilizing the Hamburg Approach in Patients With Symptomatic Drug-Refractory Paroxysmal Atrial Fibrillation.

Circumferential pulmonary vein isolation (CPVI) is increasingly performed for the treatment of symptomatic drug-refractory paroxysmal atrial fibrillation. Long-term data for >10 years after CPVI are sparse. We investigated the long-term clinical outcome and progression of paroxysmal atrial fibrillation after double-lasso and 3-dimensional electroanatomical mapping-guided CPVI. From 2003 to 2004, 161 patients (mean age: 60±10 years) with symptomatic drug-refractory paroxysmal atrial fibrillation were prospectively enrolled and underwent electroanatomical mapping-guided CPVI. Right-sided and left-sided continuous circular lesions encircling the ipsilateral pulmonary veins were placed with irrigated radiofrequency energy. The procedural end point was the absence of pulmonary vein spikes 30 minutes after CPVI verified by 2 spiral catheters placed within the ipsilateral pulmonary veins (double-lasso technique). Major periprocedural complications occurred in 5 of 161 patients (3.1%). Follow-up was based on outpatient clinic visits, including Holter-ECGs and telephonic interviews. After a single procedure and median follow-up of 129.0 months (interquartile range, 124.7-133.1 months), stable sinus rhythm was present in 53 of 161 (32.9%) patients. Multiprocedural outcome after a mean of 1.73±0.9 procedures and a median follow-up of 123.4 months (interquartile range, 61.0-131.0 months) resulted in stable sinus rhythm in 101 of 161 patients (62.7%). Progression toward persistent atrial fibrillation was observed in 10 of 161 patients (6.2%). Ten-year single-procedural outcome of CPVI in patients with paroxysmal atrial fibrillation resulted in stable sinus rhythm in 32.9% and in 62.7% of patients after multiple procedures. The progression rate to persistent AF was remarkably low.

Adjunctive interpulmonary isthmus ablation has no added effects on atrial fibrillation recurrence

ObjectiveData on the efficacy of adjunctive interpulmonary isthmus ablation following completion of extensive encircling pulmonary vein isolation (EEPVI) on atrial fibrillation (AF) recurrence have still been insufficient. We aimed to...

Patterns of Pulmonary Vein Potential Disappearance During Encircling Ipsilateral Pulmonary Vein Isolation Can Predict Recurrence of Atrial Fibrillation

The relationship between pulmonary vein (PV) potential (PVP) disappearance patterns during encircling ipsilateral pulmonary vein isolation (EIPVI) of atrial fibrillation (AF), and outcome was examined. A total of 352 consecutive AF patients (age, 61±12 years; 269 men, 76.4%; paroxysmal AF, n=239; persistent AF, n=73; and long-standing persistent AF, n=40) who underwent initial AF ablation were studied. After EIPVI with a double Lasso technique, pacing was performed from the PV carina to confirm isolation of the carina. PVP disappearance patterns were classified into 3 types: A, both superior and inferior PVP disappeared simultaneously; B, superior and inferior PVP disappeared separately; and C, additional RF applications were required inside the encircling lesions to eliminate the PVP after creating anatomical encircling lesions. The relationship between these patterns and outcome was examined. Six groups were defined according to the combination of right and left ipsilateral PVP disappearance patterns. The incidence of A-A, A-B, B-B, A-C, B-C, and C-C was 7.1%, 14.2%, 16.2%, 15.3%, 27.3%, and 19.9%, respectively. AF recurrence-free rate at 2 years for these 6 groups was 96%, 81%, 78%, 64%, 64%, and 59%, respectively (P<0.02). The incidence of a carina isolation was 153/154 (99.4%) for type A, 221/259 (85.3%) for type B, and 145/290 (50.0%) for type C. PVP disappearance pattern during EIPVI was significantly associated with the incidence of residual PV carina conduction and AF recurrence.

Six-Year Follow-up of Catheter Ablation in Paroxysmal Atrial Fibrillation

Although pulmonary vein (PV) antrum isolation is an established therapy for drug-resistant paroxysmal atrial fibrillation (PAF), long-term (>5 years) follow-up data are limited. This study investigated long-term clinical outcome of catheter ablation. From September 2003 to August 2006, 161 patients (mean age, 60±9 years; 119 male) with symptomatic drug-refractory PAF who underwent extensive encircling PV isolation (EEPVI) with a double Lasso technique were included. Right-sided and left-sided circular lesions encircling the ipsilateral PVs were created. The procedure endpoint was electrical isolation of the PV antrum. Patients with recurrent atrial tachyarrhythmia (ATa) had their previous lesions assessed and consolidated. Trigger ablation was added if necessary. EEPVI was successfully performed at the initial procedure. During a median follow-up of 6.4 years (25th-75th percentile, 5.8-7.1 years), 86 patients (53.4%) had recurrent ATa. Among 78, 15 and 4 patients undergoing 2nd, 3rd and 4th procedures, PV reconnections were observed in 68, 10 and 2, respectively. During a median follow-up of 6.0 years (25th-75th percentile, 5.2-6.9 years) after a mean of 1.6±0.7 procedures per patient, 144 patients (89.4%) were free from ATa. No progression toward persistent AF was observed in any patients. The vast majority of drug-resistant PAF could be controlled by EEPVI without an additional atrial substrate modification. No progression toward persistent AF was observed during a median follow-up of 6 years.

The incidence and clinical significance of non-isolation of the pulmonary vein carina after encircling ipsilateral pulmonary veins isolation for paroxysmal atrial fibrillation: a pitfall of the double-Lasso technique

Encircling ipsilateral pulmonary veins (PVs) isolation (EIPVsI) with the double-Lasso technique has proven to be effective to cure atrial fibrillation (AF). However, in this technique, PV mapping with circular catheters may miss a non-isolation of the PV carina. The purpose of this study was to reveal the incidence and clinical significance of a non-isolation of the PV carina after EIPVsI. We studied 81 consecutive paroxysmal AF patients (age 61 ± 12 years, 56 men), in whom EIPVsI was successfully performed in one encircling line with the endpoint of the demonstration of bidirectional conduction block between the PVs and left atrium (LA) with the double-Lasso technique. After a successful EIPVsI, pacing from the PV carina was performed and it captured the LA in 17 (21.0%) patients. During a mean follow-up period of 19 ± 13 months, AF recurred in 13 (16.0%) patients. A multivariate Cox proportional analysis revealed that a non-isolation of the PV carina after the EIPVsI was a significant predictor (hazard ratio = 3.91, 95% confidence interval = 1.13-14.16, P = 0.03) of AF recurrence. Pulmonary vein mapping with the double-Lasso technique did miss the non-isolation of the PV carina after a successful EIPVsI, which was an independent predictor of AF recurrence after the EIPVsI. Pacing from the PV carina may be required to confirm the electrical isolation of the PV carina after EIPVsI with the double-Lasso technique.

Impact of diastolic dysfunction on the outcome of catheter ablation in patients with atrial fibrillation

ObjectiveTo evaluate the impact of diastolic dysfunction on the outcome of atrial fibrillation (AF) ablation. MethodsEighty consecutive patients with drug-refractory symptomatic AF who underwent AF ablation were enrolled (65 males, 58±10years, 65 paroxysmal AF, 15 persistent AF). All patients underwent extensive pulmonary vein isolation with a double lasso technique using CARTO MERGE. Diastolic dysfunction was defined as a ratio of the mitral inflow early filling velocity to the velocity of the early medial mitral annular ascent of >10. The clinical and echocardiographic data were compared between the patients with and without diastolic dysfunction, and between the patients with and without AF recurrences after the AF ablation. ResultsTwenty-nine out of all the patients (36.3%) had diastolic dysfunction. Compared with the patients without diastolic dysfunction, the patients with diastolic dysfunction had higher brain natriuretic peptide (p=0.001) and C-reactive protein (p=0.023) levels, and a larger left atrial diameter (P=0.019). The AF-free rate after a single or repeat AF ablation procedure in the patients with diastolic dysfunction was lower than that in those without diastolic dysfunction (p=0.005 and p=0.013 by the log-rank test, respectively). In the univariate analysis, the patients with persistent AF and diastolic dysfunction were likely to have AF recurrences after a single AF ablation. The multivariate analysis indicated diastolic dysfunction as the only independent predictor of an AF recurrence after a single AF ablation (P=0.023). ConclusionThe patients with diastolic dysfunction had a worse outcome of the AF ablation not only for a single procedure but also a repeat procedure.

The Effect of Arterial Stiffness on Recurrence of Paroxysmal Atrial Fibrillation after Catheter Ablation

Purpose: The aim of this study was to investigate the relationship between arterial stiffness and atrial fibrillation (AF) recurrence after catheter ablation (CA). Methods: We enrolled 94 consecutive patients (mean age: 62±9.5) undergoing circumferential pulmonary vein electrical isolation with a double lasso technique using CARTO system for paroxysmal AF. Cardio-ankle vascular index (CAVI) was determined as an index of arterial stiffness. Plasma BNP, serum aldosterone, and high sensitivity CRP were assayed, and Left atrial volume (LAV) was measured by multi-slice CT. Results: Among the 94 patients, 26 (28%) had metabolic syndrome. In simple regression analysis, CAVI were correlated with age, eGFR, BNP, and LAV (p<0.001, p<0.05, p<0.01, p<0.05, respectively). During a follow-up of 7.9±2.3 months, 21 patients experienced AF recurrence. Patients with AF recurrence had a increased CAVI (recurrence 8.9 vs non-recurrence 8.2 p<0.05) and a larger LAV (recurrence 81.3 ml vs non-recurrence 70.6 ml p<0.05) compared with patients without AF recurrence. Multivariate analysis revealed that LAV, BNP, CAVI were independently associated with AF recurrence (t-value: 2.76, 4.65, 2.28, respectively). Conclusions: CAVI was associated with age, BNP and LAV, suggesting a significant role of arterial stiffness in AF after CA.

Validation of Irrigated Ablation for Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation

Background: Irrigation catheter (Ir–C) is in the process of spreading, however, various aspects of efficient and safe usage are well-known. Methods: Consecutive 122 patients with drug-resistant, paroxysmal atrial fibrillation who underwent extensive pulmonary vein isolation (PVI) using Ir–C were analyzed. PVI were performed with irrigated radiofrequency energy, maximum temperature of 42 °C, power of 25–35 W with constant 17–30 ml/min saline infusion. Right-sided and left-sided circular lesions on left atrial antrum encircling the ipsilateral PVs were placed, guided by 3-dimensional mapping and double Lasso technique. Results: PVI was achieved in all patients, and no major complications related to Ir–C usage were observed. During one application, mean impedance decrease was 13±6 ohm. In the cases with mean time of less than 40 sec for one application (34.9±3.8 sec, n=71), compared with cases with mean time of more than 40 sec for one application (43.1±2.7 sec, n=51), the number of applications was large (58±14 vs. 48±14, p<0.001), procedure time was longer (69±31 vs. 58±22 min, p<0.05), and fluoroscopic time was longer (37±15 vs. 32±11 min, p<0.05). Conclusions: Ir–C was effective and safety for PVI. Applications within mean time of 40 sec might need additional applications, and consequently increased procedure time and fluoroscopic time.

Long-Term Results of Catheter Ablation in Paroxysmal Atrial Fibrillation

Background— Paroxysmal atrial fibrillation (AF) naturally progresses toward chronic AF at an estimated rate of 15% to 30% over a 1- to 3-year period. Pulmonary vein (PV) isolation is increasingly performed for the treatment of drug-refractory paroxysmal AF. The long-term data on clinical outcome after circumferential PV isolation are limited. Methods and Results— From 2003 to late 2004, 161 patients (121 men; age, 59.8±9.7 years) with symptomatic paroxysmal AF and normal left ventricular function underwent circumferential PV isolation guided by 3-dimensional mapping and double Lasso technique. Right-sided and left-sided continuous circular lesions encircling the ipsilateral PVs were placed with irrigated radiofrequency energy. The procedure end point was the absence of all PV spikes for at least 30 minutes after PV isolation verified by 2 Lasso catheters placed within the ipsilateral PVs. Sinus rhythm was present in 75 patients (46.6%) after the initial procedure during a median follow-up period of 4.8 years (0.33 to 5.5 years). A second procedure was performed in 66 and a third procedure in 12 patients. Recovered PV isolation conduction was observed in 62 of 66 patients (94.0%) during the second and in 8 of 12 patients (66.7%) during the third procedure. After a median of 1 (1 to 3) procedure, stable sinus rhythm was achieved in 128 of 161 patients (79.5%), whereas clinical improvement occurred in an additional 21 of 161 patients (13.0%) during a median follow-up of 4.6 years (0.33 to 5.5 years). Four patients in stable sinus rhythm died during follow-up. Progression toward chronic AF was observed in 4 patients (2.4%); however, only 2 patients reported symptoms. Conclusion— In patients with paroxysmal AF and normal left ventricular function, circumferential PV isolation results in stable sinus rhythm in the majority of patients, and low incidence of chronic AF was observed after ablation during up to 5 years of follow-up.

No severe pulmonary vein stenosis after extensive encircling pulmonary vein isolation: 12-month follow-up with 3D computed tomography

Few studies have explored the utility of local electrogram-guided extensive encircling pulmonary vein isolation (EEPVI) by analyzing the pulmonary vein (PV) anatomy and occurrence of stenosis using multidetector computed tomography (MDCT). One hundred seventy-six paroxysmal atrial fibrillation (AF) patients underwent EEPVI with a double lasso technique. MDCT was performed in all patients before and at 3, 6 and 12 months after the ablation procedures to screen for PV stenosis. PV stenosis was defined as a >30% reduction in its diameter. A total of 700 PVs were analyzed. PV stenosis was observed in 15 of 700 PVs (2.1%). All stenoses were mild (mean 34.5 ± 3.3%). They were all asymptomatic, and none required treatment. After 12 months of follow-up, the PV narrowing regressed significantly compared with that at 3 months in the patients with PV stenosis (34.5 ± 3 to 30.4 ± 5%, P < 0.05). The remaining PVs exhibited a stable anatomy, and there was no significant progression of the PV narrowing. The results of this study demonstrated that detectable PV stenosis occurred in 2.1% of the PVs, and all stenoses were mild. Moreover, a significant regression of the PV narrowing was observed after 12-months of follow-up. This indicates that the local electrocardiogram-guided EEPVI was relatively safe regarding severe PV stenosis.

Catheter Ablation of Atrial Fibrillation in Patients With Valvular Heart Disease: Long‐Term Follow‐Up Results

AF Ablation in Patients With Valvular Heart Disease. The purpose of this study is to evaluate the efficacy of atrial fibrillation (AF) ablation in patients with moderate valvular heart disease (VHD). In total, 534 consecutive patients who underwent AF ablation were enrolled. Patients with a history of valve surgery or other structural heart disease were excluded. Patients with clinically moderate VHD (group-1, n = 45) were compared with those without VHD (control group-2, n = 436). Ipsilateral pulmonary vein antrum isolation (PVAI) was performed with a double Lasso technique in all the patients. Left atrial (LA) linear ablation was undertaken in persistent AF patients, if AF was inducible after PVAI. Patients in group-1 were significantly older and had a larger LA. PVAI was successfully achieved in all the patients. Patients in group-1 received LA linear ablation more frequently during the index procedure. After a median of 26 months from the index procedure, the freedom from AF was significantly lower in group-1 than group-2 off antiarrhythmic drugs (AADs) (47% vs 69%, P = 0.002). Although there were more number of total procedures in group-1 than group-2, the freedom from AF was lower at median 24 months after the last procedure (78% vs 87%, P = 0.038). There was no significant difference in the freedom from AF on AADs (91% vs 95%, P = 0.356) or complication rate between the 2 groups. Atrial tachycardia following the index procedure was observed more frequently in group-1 (P = 0.001). The patients with VHD undergoing AF ablation are less likely to remain in sinus rhythm at long term without AADs than those without VHD.

ATP‐Induced Dormant Pulmonary Veins Originating from the Carina Region After Circumferential Pulmonary Vein Isolation of Atrial Fibrillation

Elimination of transient pulmonary vein recurrences (dormant PVs) induced by an ATP injection and ablation at the PV carina region is an effective strategy for atrial fibrillation (AF) ablation. The relationship between dormant PVs and the PV carina region has not been evaluated. A total of 212 consecutive symptomatic AF patients underwent circumferential PV electrical isolation (CPVEI) with a double lasso technique. They were divided into 2 groups in a retrospective review; Group 1: those given an ATP injection during an intravenous isoproterenol infusion after the CPVEI (n = 106), and Group 2: those in which it was not given after the CPVEI (n = 106). Radiofrequency energy was applied at the earliest dormant PV activation site identified using a Lasso catheter on the CPVEI line and then PV carina region if it was ineffective. After a successful PVEI, 54 patients (51%) in Group 1 had PV reconnections during an ATP injection. Acute PVEI sites were observed on the carina region within the CPVEI line in the right PVs (16%) and left PVs (10%). Dormant PVs were reisolated at the carina region in the right PVs (23%) and left PVs (26%). The distribution of the dormant PV sites, except for the RIPV, significantly differed from that of the acute PVEI sites (P < 0.05). Further, AF recurred significantly in the Group 2 patients as compared to those in Group 1 during 16 +/- 6.1 months of follow-up (P < 0.05). PV carina region origins may partly be responsible for an acute PVEI and potential recurrences.

A unique iatrogenic organized left atrial tachycardia with a gap conduction in previously ablated lesions

This case concerns a 57-year-old woman with an organized left atrial tachycardia (AT) after pulmonary vein (PV) isolation. The left inferior PV (LIPV) exhibited a figure of eight tachycardia around the LIPV ostium with one loop at the anterior aspect and another at the posterior aspect, which corresponded to regular surface P waves. Although a gap ablation of fractionated electrograms changed the LIPV sequence, the atrial potentials were organized with a shortened cycle length accompanied by the same surface P-wave morphology. The elimination of the anterior loop and modification of the posterior loop after the gap ablation might have yielded that specific sequence change of the AT.

Inducibility of atrial tachyarrhythmias after circumferential pulmonary vein isolation in patients with paroxysmal atrial fibrillation: clinical predictor and outcome during follow-up

AimsWe investigated the presence and clinical outcome of inducibility of atrial tachyarrhythmias after circumferential pulmonary vein isolation (CPVI) in patients with paroxysmal atrial fibrillation (PAF).Methods and resultsSixty patients with symptomatic PAF underwent CPVI guided by 3D mapping and double Lasso technique. After achievement of CPVI, the induction was performed. The left atrium (LA) volume and the isolated LA area around the right and left-sided pulmonary veins were measured by the 3D mapping system. Sustained atrial tachyarrhythmias (>10 min) were induced after CPVI in 17 of 60 patients (28%). Patients with inducible atrial tachyarrhythmias had significantly smaller isolated areas when compared with the group with non-inducible tachyarrhythmias (16.7 ± 2.3 vs. 18.8 ± 2.9%, P < 0.05). After the initial procedure, recurrence occurred in 18 of 43 (42%) patients in the non-inducible group and in 7 of 17 (41%) in the inducible group during follow-up. A repeat procedure was performed in all 25 patients with recurrence. Five patients had a recurrence after the repeat procedure during 20.8 ± 7.5 months, and there was no difference between the two groups.ConclusionInducibility of atrial tachyarrhythmias is associated with proportionally smaller isolated area and does not predict the clinical efficacy of CPVI in patients with PAF.

Letter by Kriatselis and Roser Regarding Article, “Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation? Results From a Prospective Randomized Study”

HomeCirculationVol. 116, No. 25Letter by Kriatselis and Roser Regarding Article, “Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation? Results From a Prospective Randomized Study” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Kriatselis and Roser Regarding Article, “Small or Large Isolation Areas Around the Pulmonary Veins for the Treatment of Atrial Fibrillation? Results From a Prospective Randomized Study” Charalampos Kriatselis, MD and Mattias Roser, MD Charalampos KriatselisCharalampos Kriatselis Department of Cardiology, German Heart Institute Berlin, Berlin, Germany Search for more papers by this author and Mattias RoserMattias Roser Department of Cardiology, German Heart Institute Berlin, Berlin, Germany Search for more papers by this author Originally published18 Dec 2007https://doi.org/10.1161/CIRCULATIONAHA.107.725374Circulation. 2007;116:e575To the Editor:We read with interest the article by Arentz et al1 that compared the outcome of small and large isolation areas around the pulmonary veins. Large-area isolation was guided anatomically with ablation lesions targeted outside of the pulmonary vein ostia (>1 cm on the posterior and >5 mm on the anterior walls), whereas small-area isolation targeted ablation at the ostial position.Mapping of the pulmonary veins for local potentials was performed sequentially with a single catheter (either a 64-pole basket catheter or a 20-pole circular mapping catheter). In our opinion, this asynchrony imposes a major limitation on the comparability of the 2 approaches. It has been shown2,3 that during inspiration, the location of the ostia of the pulmonary veins, especially of the inferior pulmonary vein, changes significantly. For that reason, delivery of radiofrequency energy at about 5 to 10 mm outside the pulmonary vein ostia, for example for 60 s, might lead to significant radiofrequency energy delivery directly at the ostial site of the pulmonary veins (eg, for an inspiration duration of about 2 s and approximately 10 inspiration/expiration cycles in 60 s, about 20 s of radiofrequency energy would be delivered). Under some circumstances, this could lead to sequential and rather ostial isolation, even if the intention was to isolate the pulmonary veins simultaneously through a large isolation line. We believe that only the combination of the anatomic approach with demonstration of simultaneous disappearance of the potentials in both ipsilateral veins, using the double Lasso technique,4 can prove large-area isolation.DisclosuresNone. References 1 Arentz T, Weber R, Bürkle G, Herrera C, Blum T, Stockinger J, Minners J, Neumann FJ, Kalusche D. Small or large isolation areas around the pulmonary veins for the treatment of atrial fibrillation? Results from a prospective randomized study. Circulation. 2007; 115: 3057–3063.LinkGoogle Scholar2 Noseworthy P, Malchano Z, Ahmed J, Holmvang G, Ruskin J, Reddy V. The impact of respiration on left atrial and pulmonal venous anatomy: implications for image-guided intervention. Heart Rhythm. 2005; 2: 1173–1178.CrossrefMedlineGoogle Scholar3 Ector J, Loeckx D, Coudijzer W, De Buck S, Maes F, Dymarkowski S, Bogaert J, Heidbüchel H. Images in cardiovascular medicine: changes in left atrial and pulmonary venous anatomy during respiration: a 4-dimensional computed tomography–based assessment and implications for atrial fibrillation ablation. Circulation. 2007; 115: e617–e619.LinkGoogle Scholar4 Ouyang F, Bänsch D, Ernst S, Schaumann S, Hachiya H, Chen M, Chun J, Falk P, Khanedani A, Antz M, Kuck KH. Complete isolation of the left atrium surrounding the pulmonary veins: new insights from the double Lasso technique in paroxysmal atrial fibrillation. Circulation. 2004; 110: 2090–2096.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails December 18, 2007Vol 116, Issue 25 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.725374PMID: 18086937 Originally publishedDecember 18, 2007 PDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-Defibrillator

Pulmonary Vein Conduction Is the Major Finding in Patients with Atrial Tachyarrhythmias after Intraoperative Maze Ablation

Electrophysiological (EP) data from patients with recurrent atrial tachyarrhythmias (ATa) after intraoperative maze ablation are limited. Furthermore, the clinical course after accomplishing pulmonary vein (PV) isolation using the double lasso technique (DLT) is unknown. EP study and catheter ablation (CA) was guided by a three-dimensional electroanatomic mapping system (3-D EA, CARTO, Biosense-Webster) combined with simultaneous ipsilateral PV mapping using the DLT. Defined endpoints were: (1) identification of conduction gaps within the ipsilateral PVs, (2) elimination of all PV spikes, and (3) ablation of clinical ATas. CA was performed in eight patients (four females, 62 +/- 5 years, LA: 50 +/- 6 mm) with drug refractory ATa (9.1 +/- 6.3 years) despite non-"cut and sew" maze operation. Electrical PV conduction was demonstrated in the majority of patients (7/8). All endpoints were achieved. Repeat ablations were required in three patients. Second ablation was due to typical atrial flutter (n = 1) and atrial fibrillation (n = 2). One patient required three ablations due to a left atrial macroreentrant tachycardia. During a mean follow-up of 15.5 +/- 4.8 months, 7/8 patients were free of ATa recurrences. Incomplete lesions after non-"cut and sew" maze operation are associated with PV conduction and recurrence of ATas. Electrical isolation of ipsilateral PVs and completion of linear lesions guided by 3-D EA mapping is feasible and successful in maintaining sinus rhythm during mid term follow-up. Completeness of linear lesions using EP endpoints should be confirmed during the initial surgical procedure to minimize ATa recurrences.

Electrophysiological Findings During Ablation of Persistent Atrial Fibrillation With Electroanatomic Mapping and Double Lasso Catheter Technique

Pulmonary veins (PVs) can be completely isolated with continuous circular lesions (CCLs) around the ipsilateral PVs. However, electrophysiological findings have not been described in detail during ablation of persistent atrial fibrillation (AF). Forty patients with symptomatic persistent AF underwent complete isolation of the right-sided and left-sided ipsilateral PVs guided by 3D mapping and double Lasso technique during AF. Irrigated ablation was initially performed in the right-sided CCLs and subsequently in the left-sided CCLs. After complete isolation of both lateral PVs, stable sinus rhythm was achieved after AF termination in 12 patients; AF persisted and required cardioversion in 18 patients. In the remaining 10 patients, AF changed to left macroreentrant atrial tachycardia in 6 and common-type atrial flutter in 4 patients. All atrial tachycardias were successfully terminated during the procedure. Atrial tachyarrhythmias recurred in 15 of 40 patients at a median of 4 days after the initial ablation. A repeat ablation was performed at a median of 35 days after the initial procedure in 14 patients. During the repeat study, recovered PV conduction was found in 13 patients and successfully abolished by focal ablation of the conduction gap of the previous CCLs. After a mean of 8+/-2 months of follow-up, 38 (95%) of the 40 patients were free of AF. In patients with persistent AF, CCLs can result in either AF termination or conversion to macroreentrant atrial tachycardia in 55% of the patients. In addition, recovered PV conduction after the initial procedure is a dominant finding in recurrent atrial tachyarrhythmias and can be successfully abolished.

Recovered Pulmonary Vein Conduction as a Dominant Factor for Recurrent Atrial Tachyarrhythmias After Complete Circular Isolation of the Pulmonary Veins. Lessons From Double Lasso Technique

Recovered Pulmonary Vein Conduction as a Dominant Factor for Recurrent Atrial Tachyarrhythmias After Complete Circular Isolation of the Pulmonary Veins. Lessons From Double Lasso Technique