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Arrhythmia Management
confirmation of denervation. Complete local vagal denervation is defined by Post-ablation Artrial Fibrillation
the abolition of all vagal reflexes. Based on our experience, we always If targets are successfully achieved in the index procedure, post-ablation ATs
attempt to elicit and then ablate potential sites of reflexes for vagal may develop in fewer than 5% of patients, and usually are macro- or micro-
denervation. We reported a detailed ‘autonomic map’ of the left atrium as re-entrant gap-related rather than focal tachycardias.
13
In our extensive
a target for ablation, showing that, like the left superior PV, the septal experience, these ATs should initially be treated conservatively, with medical
region is richly innervated.
11
therapy and cardioversion.
13–16
Only incessant ATs in symptomatic patients
require a repeat procedure with accurate mapping to optimise ablation
Linear Lesions therapy, which will lead to a cure in most cases.
13–16
Additional ablation lines alter the AF substrate by eliminating large
macro-re-entrant circuits able to sustain AF and/or AT.
10–16
Standard Technical Improvement
CPVA linear lesions include the mitral isthmus line, the roof line and the Currently, most catheter ablation procedures in patients with AF are
posterior wall line.
11–16
Multiple additional linear lesions in the left atrium performed with manual catheters, which requires advanced operator skills
or right atrium (bi-atrial lesions) are required in patients with permanent and experience with catheter manipulation and ablation. The feasibility of
AF to obtain stable sinus rhythm or AF/AT non-inducibility at the end of the remote system, which is not operator-dependent, may represent an
the index procedure (CPVA stepwise approach). Each ablation target is attractive alternative approach in many laboratories worldwide to
performed sequentially based on the cumulative increase of AF cycle reproduce the success rates of the pioneering groups while minimising
length until conversion to sinus rhythm or an AT, which is then mapped risks.
16–18
Currently, two main systems for magnetic and robotic navigation
conventionally and ablated.
10
In our experience, completeness of lesion are available for clinical use (Stereotaxis and Hansen systems, respectively).
lines is important, but in many cases achievement of complete block is The recent availability of remote tip-irrigated magnetic catheters will
unnecessary – particularly in the mitral isthmus line, where a delay of enhance the benefits of the remote magnetic system (Stereotaxis), making
about 100ms is sufficient to prevent post-ablation macro-re-entrant left deeper lesions than with manual catheters regardless of the operator’s
AT. If necessary, adjunctive linear ablation (usually the septum or the base experience. At present, limited data are available on the efficacy and safety
of the left anterior ascending [LAA]) is performed before CS isolation, profile of balloon technology. Balloon technology for PV isolation is not
which is the last target. frequently used, as in most patients with AF catheter ablation is not limited
to PV disconnection alone, and the achievement of additional multiple
Coronary Sinus Disconnection targets precludes its use. In addition, PVs have largely variable anatomies
If AF/AT inducibility persists even after cardioversion, we accurately revisit from patient to patient, with a wide range of diameters, and the frequent
lesion lines and encircled areas to check for residual potentials, and apply presence of common ostia in up to 30% of patients makes the use of
RF where needed. Conduction block is assessed by the presence of a balloon-based catheters challenging.
corridor of double potentials and demonstration of activation moving
towards the line of block on both sides. Rapid atrial activity from the Conclusions
musculature of the CS may be a driver for long-lasting or permanent AF. Catheter ablation of AF may provide a true cure rather than only palliative
Electrical disconnection of the coronary sinus from the atrium is therapy, as provided by ADT, in most patients with AF. The first randomised
performed by endocardial or epicardial ablation, or both. Total elimination trials comparing catheter ablation with long-term ADT in patients with AF
of CS activity is the ideal end-point, but organisation of CS activity and/or demonstrated a striking superiority of ablation with higher efficacy, lower
slowing of local rate with dissociation between CS and left atrium morbidity and improved quality of life. In patients with long-lasting or
potential activity is also considered proof of CS isolation. Endocardial permanent AF, multiple sequential lesions and repeat procedures are still
and/or epicardial CS sites are frequent ablation targets in patients with required to achieve a stable sinus rhythm, which emphasises the need for
permanent AF and enlarged atria. a tailored approach to limit extensive unnecessary bi-atrial lesions. ■
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guidelines for the management of patients with atrial 6. Wazni OM, Marrouche NF, Martin DO, et al., Radiofrequency remodeling after circumferential radiofrequency pulmonary vein
fibrillation: a report of the American College of Cardiology, ablation vs antiarrhythmic drugs as first-line treatment of ablation: efficacy of an anatomic approach in a large cohort of
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and the European Society of Cardiology Committee for Practice 2005;293:2634–40. 13. Pappone C, Manguso F, Vicedomini G, et al., Prevention of
Guidelines (writing committee to revise the 2001 guidelines for 7. Stabile G, Bertaglia E, Senatore G, et al., Catheter ablation iatrogenic atrial tachycardia after ablation of atrial fibrillation: a
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98 EUROPEAN CARDIOLOGY
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