Impact of Posterior Wall Isolation During AF Ablation on the Incidence of Left Atrial Flutter.

atrial fibrillation atypical flutter posterior wall isolation

Journal

JACC. Clinical electrophysiology
ISSN: 2405-5018
Titre abrégé: JACC Clin Electrophysiol
Pays: United States
ID NLM: 101656995

Informations de publication

Date de publication:
09 May 2024
Historique:
received: 14 03 2024
revised: 22 04 2024
accepted: 22 04 2024
medline: 16 5 2024
pubmed: 16 5 2024
entrez: 16 5 2024
Statut: aheadofprint

Résumé

Linear and complex electrogram ablation (LCEA) beyond pulmonary vein isolation (PVI) is associated with an increase in left atrial macro-re-entrant tachycardias (LAMTs). Posterior wall isolation (PWI) is increasingly performed to improve AF ablation outcomes. However, the impact of PWI on the incidence of LAMT is unknown. The purpose of this study was to establish the incidence of LAMT following PVI alone vs PVI + PWI vs PVI + PWI + LCEA. Consecutive patients undergoing catheter ablation for AF or LAMT post-AF ablation between 2008 and 2022 from 4 electrophysiology centers were reviewed with a minimum follow-up of 12 months. In total, 5,619 (4,419 index, 1,100 redo) AF ablation procedures were performed in 4,783 patients (mean age 60.9 ± 10.6 years, 70.7% men). Over a mean follow-up of 6.4 ± 3.8 years, 246 procedures for LAMT were performed in 214 patients at a mean of 2.6 ± 0.6 years post-AF ablation. Perimitral (52.8% of patients), roof-dependent (27.1%), PV gap-related (17.3%), and anterior circuits (8.9%) were most common, with 16.4% demonstrating multiple circuits. The incidence of LAMT was significantly higher following PVI + PWI (6.2%) vs PVI alone (3.0%; P < 0.0001) and following PVI + PWI + LCEA vs PVI + PWI (12.5%; P = 0.019). Conduction gaps in previous ablation lines were responsible for LAMT in 28.4% post-PVI alone, 35.3% post-PVI + PWI (P = 0.386), and 81.8% post-PVI + PWI + LCEA (P < 0.005). The incidence of LAMT following PVI + PWI is higher than with PVI alone but significantly lower than with more extensive atrial substrate modification. Given a low frequency of LAMT following PWI, empiric mitral isthmus ablation is not justified and may be proarrhythmic.

Sections du résumé

BACKGROUND BACKGROUND
Linear and complex electrogram ablation (LCEA) beyond pulmonary vein isolation (PVI) is associated with an increase in left atrial macro-re-entrant tachycardias (LAMTs). Posterior wall isolation (PWI) is increasingly performed to improve AF ablation outcomes. However, the impact of PWI on the incidence of LAMT is unknown.
OBJECTIVES OBJECTIVE
The purpose of this study was to establish the incidence of LAMT following PVI alone vs PVI + PWI vs PVI + PWI + LCEA.
METHODS METHODS
Consecutive patients undergoing catheter ablation for AF or LAMT post-AF ablation between 2008 and 2022 from 4 electrophysiology centers were reviewed with a minimum follow-up of 12 months.
RESULTS RESULTS
In total, 5,619 (4,419 index, 1,100 redo) AF ablation procedures were performed in 4,783 patients (mean age 60.9 ± 10.6 years, 70.7% men). Over a mean follow-up of 6.4 ± 3.8 years, 246 procedures for LAMT were performed in 214 patients at a mean of 2.6 ± 0.6 years post-AF ablation. Perimitral (52.8% of patients), roof-dependent (27.1%), PV gap-related (17.3%), and anterior circuits (8.9%) were most common, with 16.4% demonstrating multiple circuits. The incidence of LAMT was significantly higher following PVI + PWI (6.2%) vs PVI alone (3.0%; P < 0.0001) and following PVI + PWI + LCEA vs PVI + PWI (12.5%; P = 0.019). Conduction gaps in previous ablation lines were responsible for LAMT in 28.4% post-PVI alone, 35.3% post-PVI + PWI (P = 0.386), and 81.8% post-PVI + PWI + LCEA (P < 0.005).
CONCLUSIONS CONCLUSIONS
The incidence of LAMT following PVI + PWI is higher than with PVI alone but significantly lower than with more extensive atrial substrate modification. Given a low frequency of LAMT following PWI, empiric mitral isthmus ablation is not justified and may be proarrhythmic.

Identifiants

DOI: 10.1016/j.jacep.2024.04.008 PMID: 38752960
pubmed: 38752960
pii: S2405-500X(24)00286-X
doi: 10.1016/j.jacep.2024.04.008
pii:
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Informations de copyright

Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Déclaration de conflit d'intérêts

Funding Support and Author Disclosures Dr Lim is supported by a NHMRC postgraduate scholarship. Dr Ling has received grants from Abbott Australia. Dr Sugumar has received grants from the RACP Foundation. Prof Prabhu has received grants from NHMRC, University of Melbourne, and Baker Heart and Diabetes Institute; has received postdoctoral fellowship support from the Heart Foundation; has received advisory fees from Biosense Webster; and has received speaker fees from Abbott Medical. Prof Kalman is supported by an NHMRC practitioner fellowship; and has received research support from Biosense Webster and Medtronic. Prof Kistler is a recipient of an Investigatorship from the NHMRC of Australia; has received grants from Baker Department of Metabolic Health and University of Melbourne; and has received speaker fees from Abbott Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Auteurs

Michael W Lim (MW)

The Alfred Hospital, Melbourne, Australia; The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.

Matthew Morton (M)

Monash University, Melbourne, Australia.

Romaniya Fernando (R)

Cabrini Health, Melbourne, Australia.

Stefanie Elbracht-Leong (S)

Cabrini Health, Melbourne, Australia.

Nathan Better (N)

The Royal Melbourne Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia.

Louise Segan (L)

The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.

Jeremy William (J)

The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.

Rose Crowley (R)

The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.

Joseph B Morton (JB)

The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia.

Paul B Sparks (PB)

The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia.

Geoffrey Lee (G)

The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia.

Alex J McLellan (AJ)

The Royal Melbourne Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; St Vincent's Health, Melbourne, Victoria, Australia.

Liang-Han Ling (LH)

The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia.

Hariharan Sugumar (H)

The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; Monash University, Melbourne, Australia; St Vincent's Health, Melbourne, Victoria, Australia.

Sandeep Prabhu (S)

The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia.

Aleksandr Voskoboinik (A)

The Alfred Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Western Health, Melbourne, Victoria, Australia.

Jonathan M Kalman (JM)

The Royal Melbourne Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia.

Peter M Kistler (PM)

The Alfred Hospital, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia; Cabrini Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia. Electronic address: peter.kistler@baker.edu.au.

Classifications MeSH