What is Established and What is New in Ablation of Persistent Atrial Fibrillation?

Login or register to view PDF.
Received date
25 August 2015
Accepted date
25 August 2015
DOI
https://doi.org/10.15420/aer.2015.04.02.80

Catheter-based ablation of atrial fibrillation (AF) is an established treatment option for symptomatic patients who are refractory to drug-based treatment, as implemented in the latest guidelines for the management of AF.1 The accepted and recommended cornerstone of all ablation strategies for AF is electrical isolation of the pulmonary veins (PV).2 However, in addition to PV isolation (PVI), ablation strategies for persistent or even long-standing persistent AF are heterogeneous. They may be characterised by PVI as the sole ablation target but can be extended to ablation of complex fractionated atrial electrograms (CFAE) and/or linear lesions.3–6 The recently published prospective, randomised, multicentre Substrate and Trigger Ablation for Reduction of Atrial Fibrillation (STAR-AF II) study demonstrated that pure PVI in patients with persistent AF is not less effective than more extensive ablation strategies such as ablation by way of linear lesions (mitral isthmus line and roof line) or ablation of CFAE.7

In this regard the second-generation cryoballoon has proven its potential for safe, effective and time-efficient PVI. One-year clinical outcome success after cryoballoon-based PVI in patients with paroxysmal AF (PAF) ranges between 80 % and 90 %.8–10 Cryoballoon-based PVI is also starting to demonstrate encouraging results in persistent AF; however these findings need further evaluation.11,12 In addition, novel invasive and non-invasive mapping systems allowing for focal impulse and rotor mapping (FIRM) are under investigation; they will broaden our comprehension of the underlying pathophysiology of AF and might potentially extend or change our ablation options and strategies in PAF as well as in persistent AF.13–16

References
  1. Camm AJ, Lip GY, De Caterina R, et al; ESC Committee for Practice Guidelines. 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012;33:2719–47.
    Crossref | PubMed
  2. Kirchhof P, Auricchio A, Bax J, et al. Outcome parameters for trials in atrial fibrillation: executive summary. Eur Heart J 2007;28:2803–17.
    Crossref | PubMed
  3. Nademanee K, McKenzie J, Kosar E, et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004;43:2044–53.
    Crossref | PubMed
  4. Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2010;3:32-8.
    Crossref | PubMed
  5. Tilz RR, Rillig A, Thum AM, et al. Catheter ablation of long- standing persistent atrial fibrillation: 5-year outcomes of the Hamburg Sequential Ablation Strategy. J Am Coll Cardiol 2012;60:1921–9.
    Crossref | PubMed
  6. Scherr D, Khairy P, Miyazaki S, et al. Five-year outcome of catheter ablation of persistent atrial fibrillation using termination of atrial fibrillation as a procedural endpoint. Circ Arrhythm Electrophysiol 2015;8:18–24.
    Crossref | PubMed
  7. Verma A, Jiang CY, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med 2015;372:1812–22.
    Crossref | PubMed
  8. Metzner A, Reissmann B, Rausch P, et al. One-year clinical outcome after pulmonary vein isolation using the second- generation 28-mm cryoballoon. Circ Arrhythm Electrophysiol 2014;7:288–92.
    Crossref | PubMed
  9. Wissner E, Heeger CH, Grahn H, et al. One-year clinical success of a 'no-bonus' freeze protocol using the second- generation 28 mm cryoballoon for pulmonary vein isolation. Europace 2015;17:1236–40.
    Crossref | PubMed
  10. Ciconte G, Ottaviano L, de Asmundis C, et al. Pulmonary vein isolation as index procedure for persistent atrial fibrillation: One-year clinical outcome after ablation using the second-generation cryoballoon. Heart Rhythm 2015;12:60–6.
    Crossref | PubMed
  11. Lemes C, Wissner E, Lin T, et al. One-year clinical outcome after pulmonary vein isolation in persistent atrial fibrillation using the second-generation 28 mm cryoballoon: a retrospective analysis. Europace 2015; pii: euv092. Epub ahead of print.
    Crossref | PubMed
  12. Ciconte G, Baltogiannis G, de Asmundis C, et al. Circumferential pulmonary vein isolation as index procedure for persistent atrial fibrillation: a comparison between radiofrequency catheter ablation and second-generation cryoballoon ablation. Europace 2015;17:559–65.
    Crossref | PubMed
  13. Narayan SM, Krummen DE, Shivkumar K, et al.Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial. J Am Coll Cardiol 2012;60:628–36.
    Crossref | PubMed
  14. Narayan SM, Krummen DE, Clopton P, et al. Direct or coincidental elimination of stable rotors or focal sources may explain successful atrial fibrillation ablation: on-treatment analysis of the CONFIRM trial (Conventional ablation for AF with or without focal impulse and rotor modulation). J Am Coll Cardiol 2013;62:138–47.
    Crossref | PubMed
  15. Revishvili AS, Wissner E, Lebedev DS, et al. Validation of the mapping accuracy of a novel non-invasive epicardial and endocardial electrophysiology system. Europace 2015;17:1282–8.
    Crossref | PubMed
  16. Haissaguerre M, Hocini M, Shah AJ, et al. Noninvasive panoramic mapping of human atrial fibrillation mechanisms: a feasibility report. J Cardiovasc Electrophysiol 2013;24:711–7.
    Crossref | PubMed