Results of a Minimally Invasive Surgical Pulmonary Vein Isolation and Ganglionic Plexi Ablation for Atrial Fibrillation: Single-Center Experience With 12-Month Follow-Up A randomized assessment of the incremental role of ablation of complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation. Noninducibility of Atrial Fibrillation as an End Point of Left Atrial Circumferential Ablation for Paroxysmal Atrial Fibrillation: A Randomized Study A randomized clinical trial of the efficacy of radiofrequency catheter ablation and amiodarone in the treatment of symptomatic atrial fibrillation. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. Catheter Ablation for Paroxysmal Atrial Fibrillation: Segmental Pulmonary Vein Ostial Ablation Versus Left Atrial Ablation Approaches to catheter ablation for persistent atrial fibrillation. Radiofrequency Ablation of Atrial Fibrillation: Is the Persistence of All Intraprocedural Targets Necessary for Long-Term Maintenance of Sinus Rhythm? Image integration-guided catheter ablation of atrial fibrillation: a prospective randomized study. Left atrial radiofrequency ablation during cardiac surgery in patients with atrial fibrillation. Left Atrial Posterior Wall Isolation Does Not Improve the Outcome of Circumferential Pulmonary Vein Ablation for Atrial Fibrillation: A Prospective Randomized Study The impact of image integration on catheter ablation of atrial fibrillation using electroanatomic mapping: a prospective randomized study. Comparison of catheter ablation and surgical ablation in patients with long-standing persistent atrial fibrillation and rheumatic heart disease: a four-year follow-up study. Circumferential Radiofrequency Ablation of Pulmonary Vein Ostia: A New Anatomic Approach for Curing Atrial Fibrillation Evaluation of linear lesions in the left and right atrium in ablation of long-standing atrial fibrillation. Is Pulmonary Vein Isolation Necessary for Curing Atrial Fibrillation? Single-Ring Posterior Left Atrial (Box) Isolation Results in a Different Mode of Recurrence Compared With Wide Antral Pulmonary Vein Isolation on Long-Term Follow-Up: Longer Atrial Fibrillation–Free Survival Time but Similar Survival Time Free of Any Atrial Arrhythmia Circumferential pulmonary-vein ablation for chronic atrial fibrillation. Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST): A 2-Center Randomized Clinical Trial Left Atrial Appendage: An Underrecognized Trigger Site of Atrial Fibrillation Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies. Phased RF ablation in persistent atrial fibrillation. Radiofrequency catheter ablation versus balloon cryoablation of atrial fibrillation: markers of myocardial damage, inflammation, and thrombogenesis
Background —The Cox Maze procedure for treatment of medically refractory atrial fibrillation ( AF ) is limited by its complexity and requirement for cardiopulmonary bypass . Long-term follow-up and success using criteria established by the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society consensus statement have not been reported for surgical AF ablation . We describe the results of using a thorascopic approach and radiofrequency energy to perform bilateral pulmonary vein isolation and left atrial ganglionic plexi ablation for treatment of AF . Methods and Results —Forty-five ( 33 paroxysmal ; 12 persistent ) consecutive patients underwent thorascopic bilateral radiofrequency pulmonary vein isolation , ganglionic plexi ablation , ligament of Marshall ablation , and left atrial appendage exclusion by a single surgeon . Forty-three patients were prospect ively followed without antiarrhythmic drugs for a minimum of 1 year with a 30-day continuous event monitor or pacemaker interrogation at 6 and 12 months . Failure was defined as any atrial tachyarrhythmia of > 30 seconds ’ duration occurring > 90 days after surgery . Mean follow-up was 516±181 days ( 202 to 858 days ) . Twenty-eight ( 65 % ) patients had no atrial tachyarrhythmia > 30 seconds by 1 year , and 15 ( 35 % ) patients had atrial tachyarrhythmia recurrences by 1 year . Eight of 15 patients with recurrent AF had catheter ablation result ing in elimination and /or reduction of AF episodes in 7 of 8 patients . Four of 15 patients had AF elimination or reduction with antiarrhythmic drugs alone . Three patients did not benefit from surgery and received rate control only . There were no deaths ; 1 phrenic nerve injury and 2 pleural effusions were the only major complications . Conclusions —The single procedure success at 1-year follow-up for surgical pulmonary vein isolation and ganglionic plexi ablation is 65 % . Atrial tachyarrhythmia recurrences after surgery are usually responsive to catheter ablation and /or antiarrhythmic drugs OBJECTIVES This study sought to determine whether ablation of complex fractionated atrial electrograms ( CFAEs ) after antral pulmonary vein isolation ( APVI ) further improves the clinical outcome of APVI in patients with long-lasting persistent atrial fibrillation ( AF ) . BACKGROUND Ablation of CFAEs has been reported to eliminate persistent AF . However , residual pulmonary vein arrhythmogenicity is a common mechanism of recurrence . METHODS In this r and omized study , 119 consecutive patients ( mean age 60 + /- 9 years ) with long-lasting persistent AF underwent APVI with an irrigated-tip radiofrequency ablation catheter . Antral pulmonary vein isolation result ed in termination of AF in 19 of 119 patients ( Group A , 16 % ) . The remaining 100 patients who still were in AF were r and omized to no further ablation and underwent cardioversion ( Group B , n = 50 ) or to ablation of CFAEs in the left atrium or coronary sinus for up to 2 additional hours of procedure duration ( Group C , n = 50 ) . RESULTS Atrial fibrillation terminated during ablation of CFAEs in 9 of 50 patients ( 18 % ) in Group C. At 10 + /- 3 months after a single ablation procedure , 18 of 50 ( 36 % ) in Group B and 17 of 50 ( 34 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.84 ) . In Group A , 15 of 19 patients ( 79 % ) were in sinus rhythm . A repeat ablation procedure was performed in 34 of 100 r and omized patients ( for AF in 30 and atrial flutter in 4 ) . At 9 + /- 4 months after the final procedure , 34 of 50 ( 68 % ) in Group B and 30 of 50 ( 60 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.40 ) . CONCLUSIONS Up to 2 h of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF Background —An anatomic approach of left atrial radiofrequency circumferential ablation ( LACA ) to encircle the pulmonary veins is often effective in eliminating  paroxysmal atrial fibrillation ( AF ) .  However , no electrophysiological end points other than voltage abatement and /or conduction slowing or block across ablation lines have been used . It has been unclear whether noninducibility of AF is a clinical ly useful end point . Methods and Results —In 100 patients with paroxysmal AF ( mean age , 55±10 years ) , LACA to encircle the left- and right-sided pulmonary veins was performed during AF , with additional ablation lines in the posterior left atrium and mitral isthmus , with an 8-mm-tip catheter . After completion of this lesion set , sinus rhythm was present , and AF lasting > 60 seconds was not inducible in 40 patients ( 40 % ; group 1 ) . The 60 patients in whom AF was still present or who still had inducible AF were r and omly assigned to no further ablation ( group 2 ; 30 patients ) or to additional ablation lines along the left atrial septum , roof , and /or anterior wall where there were fractionated electrograms ( group 3 ; 30 patients ) . In group 3 , AF was rendered noninducible in 27 of 30 patients ( 90 % ) . At a 6-month follow-up , 67 % of patients in group 2 were free of AF without drug therapy compared with 86 % of patients in group 3 . ( P=0.05 , log-rank test ) . Left atrial flutter occurred in 17 % and 27 % of patients in each group , respectively ( P=0.3 ) . Conclusions —After LACA in patients with paroxysmal AF , AF usually can be rendered noninducible by additional ablation at sites of fractionated electrograms . Noninducibility of AF attained by additional electrogram-guided left atrial ablation may be associated with a better midterm clinical outcome than when AF is still inducible after LACA alone The limited efficacy and proarrhythmic risks of antiarrhythmia agents have result ed in alternative therapeutic approaches . Radiofrequency ablation has been reported to be an effective treatment of patients with atrial fibrillation . However , there is no r and omized clinical trial comparing drug and radiofrequency ablation . The authors r and omized 30 patients with chronic atrial fibrillation refractory to medication into amiodarone and radiofrequency ablation .  The primary objective of this study was to compare the efficacy of amiodarone and radiofrequency ablation in the maintenance of sinus rhythm at 1 year after r and omization . Pulmonary vein isolation and linear ablation of right atrium was the technique used for radiofrequency ablation . There were no significant differences in baseline patient characteristics between the 2 groups . The results of this study showed that the probability of free from atrial fibrillation was better in the radiofrequency ablation group compared to amiodarone ( 78.6 % in the ablation group and 40 % in the amiodarone group , p = 0.018 ) . Radiofrequency ablation results in a significant reduction in symptoms relating to atrial fibrillation and a significant improvement in quality of life , whereas amiodarone had no significant effect on symptoms and quality of life . There was an ischemic stroke as a major complication related to radiofrequency ablation . Amiodarone was associated with adverse effects in 46.7 per cent of patients and needed discontinuation in 1 patient . In conclusion , radiofrequency ablation is an effective alternative treatment in patients with atrial fibrillation refractory to medication OBJECTIVES The aim of this study was to compare -- in patients with persistent and permanent atrial fibrillation (AF)--the  efficacy and safety of left atrial ablation with that of a biatrial approach . BACKGROUND Left atrium-based catheter ablation of AF , although very effective in the paroxysmal form of the arrhythmia , has an insufficient efficacy in patients with persistent and permanent AF . METHODS Eighty highly symptomatic patients ( age , 58.6 + /- 8.9 years ) with persistent ( n = 43 ) and permanent AF ( n = 37 ) , refractory to antiarrhythmic drugs , were r and omized to two different ablation approaches guided by electroanatomical mapping . A procedure including circumferential pulmonary vein , mitral isthmus , and cavotricuspid isthmus ablation was performed in 41 cases ( left atrial ablation group ) . In the remaining 39 patients ( biatrial ablation group ) , the aforementioned approach was integrated by the following lesions in the right atrium : intercaval posterior line , intercaval septal line , and electrical disconnection of the superior vena cava . RESULTS During follow-up ( mean duration 14 + /- 5 months ) , AF recurred in 39 % of patients in the left atrial ablation group and in 15 % of patients in the biatrial ablation group ( p = 0.022 ) . Multivariable Cox regression analysis showed that ablation technique was an independent predictor of AF recurrence during follow-up . CONCLUSIONS In patients with persistent and permanent AF , circumferential pulmonary vein ablation , combined with linear lesions in the right atrium , is feasible , safe , and has a significantly higher success rate than left atrial and cavotricuspid ablation alone Background —Segmental ostial catheter ablation ( SOCA ) to isolate the pulmonary veins ( PVs ) and left atrial catheter ablation ( LACA ) to encircle the PVs both may eliminate paroxysmal atrial fibrillation ( PAF ) .  The relative efficacy of these 2 techniques has not been directly compared . Methods and Results —Of 80 consecutive patients with symptomatic PAF ( age , 52±10 years ) , 40 patients underwent  PV isolation by SOCA and 40 patients underwent LACA to encircle the PVs . During SOCA , ostial PV potentials recorded with a ring catheter were targeted . LACA was performed by encircling the left- and right-sided PVs 1 to 2 cm from the ostia and was guided by an electroanatomic mapping system ; ablation lines also were created in the mitral isthmus and posterior left atrium . The mean procedure and fluoroscopy times were 156±45 and 50±17 minutes for SOCA and 149±33 and 39±12 minutes for LACA , respectively . At 6 months , 67 % of patients who underwent SOCA and 88 % of patients who underwent LACA  were free of symptomatic PAF when not taking antiarrhythmic drug therapy ( P = 0.02 ) . Among the variables of age , sex , duration and frequency of PAF , ejection fraction , left atrial size , structural heart disease , and the ablation technique , only an increased left atrial size and the SOCA  technique were independent predictors of recurrent PAF . The only complication was left atrial flutter in a patient who underwent LACA . Conclusions —In patients undergoing catheter ablation for PAF  , LACA to encircle the PVs is more effective than SOCA BACKGROUND Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation . Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation . METHODS We r and omly assigned 589 patients with persistent atrial fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone ( 67 patients  ) , pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity ( 263 patients  ) , or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus ( 259 patients ) . The duration of follow-up was 18 months . The primary end point was freedom from any documented recurrence of atrial fibrillation lasting longer than 30 seconds after a single ablation procedure . RESULTS Procedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures ( P<0.001 ) . After 18 months , 59 % of patients assigned to pulmonary-vein isolation alone were free from recurrent atrial fibrillation , as compared with 49 % of patients assigned to pulmonary-vein isolation plus complex electrogram ablation and 46 % of patients assigned to pulmonary-vein isolation plus linear ablation ( P=0.15 ) . There were also no significant differences among the three groups for the secondary end points , including freedom from atrial fibrillation after two ablation procedures and freedom from any atrial arrhythmia . Complications included tamponade ( three patients ) , stroke or transient ischemic attack ( three patients ) , and atrioesophageal fistula ( one patient ) . CONCLUSIONS Among patients with persistent atrial fibrillation , we found no reduction in the rate of recurrent atrial fibrillation when either linear ablation or ablation of complex fractionated electrograms was performed in addition to pulmonary-vein isolation . ( Funded by St. Jude Medical ; Clinical Trials.gov number , NCT01203748 . ) Background — Several approaches have been developed for radiofrequency catheter ablation of atrial fibrillation , but the correct intraprocedural end point is still under debate , and few data exist about the destiny of ablation lesions over time . The aim of the present study was to evaluate the long-term maintenance of intraprocedural end points of ablation procedures . Methods and Results — Inclusion criteria were ( 1 ) a previous ablation procedure of pulmonary vein ( PV ) encircling performed for drug-refractory persistent atrial fibrillation ; ( 2 ) a “ complete ” intraprocedural end point , which consisted of voltage abatement inside the lesions , PV disconnection , and exit-block pacing from inside the lesions , attained in all PVs ; and ( 3 ) stable sinus rhythm documented during a minimum follow-up of 2.5 years after the procedure . Twenty volunteers were selected ( 12 males , mean age 59±7 years ) and underwent a repeat electrophysiological study . After a follow-up of 36.4±4.7 months , complete voltage abatement was maintained around 32 PVs ( 40.0 % ) , PV disconnection persisted in 12 ( 37.5 % ) of the previously isolated PVs , and exit block was present in 39 PVs ( 48.7 % ) . Ten patients who underwent a redo ablation procedure because of recurrences of atrial fibrillation were used as the control group . Differences in intraprocedural end-point maintenance between the 2 groups were not statistically significant . Conclusions — Common intraprocedural end points such as voltage abatement , PV disconnection , and exit block persist only in a limited number of patients , even when the outcome is favorable during follow-up . Further investigation will be required to determine whether such data will have implication s for ablation strategies BACKGROUND Several studies have provided details of left atrial anatomy by means of the image integration techniques , particularly focusing on the atypical patterns of the pulmonary veins . OBJECTIVE To compare , in a prospect i ve , r and omized fashion , the conventional method of pulmonary vein disconnection and the image integration-guided approach . METHODS Two hundred and ninety consecutive patients ( 290 patients , mean age 55 + /- 11 years ) with drug-refractory paroxysmal or persistent atrial fibrillation were enrolled in the study and were divided into two treatment groups : group 1 ( 145 patients ) undergoing an imaging integration-guided ( CartoMerge TM ) ablation ; group 2 ( 145 patients ) treated by a conventional radiofrequency catheter ablation procedure .  The arrhythmia was refractory to at least two antiarrhythmic drugs ( IC , amiodarone )  . RESULTS Electrical disconnection of all identified pulmonary veins was obtained in all patients of both groups . Bidirectional block of the cavotricuspid isthmus was achieved in 34 group 1 patients and in 40 group 2 patients . Left mitral isthmus ablation was attempted in 52 group 1 patients and in 56 group 2 patients . At a mean follow-up of 14 + /- 12 months , the atrial fibrillation-free survival rate was significantly higher in group 1 patients compared with group 2 patients ( 88 % vs 69 % , P = 0.017 ) . The analysis for the subset of patients with previously ineffective ablation ( 98 patients : 52 group 1 patients and 46 group 2 patients ) showed a significantly lower recurrence rate in group 1 versus group 2 ( 19 % vs 48 % , P < 0.01 ) . CONCLUSIONS Our data indicate a superior efficacy of the image-integration guided catheter ablation of atrial fibrillation over the long term INTRODUCTION Intraoperative left atrial radiofrequency ( RF ) ablation recently has been suggested as an effective surgical treatment for atrial fibrillation ( AF ) . The aim of this study was to verify the outcome of this technique in a controlled multicenter trial . METHODS AND RESULTS One hundred three consecutive patients ( 39 men and 65 women ; age 62 + /- 11 years ) affected by AF underwent cardiac surgery and RF ablation in the left atrium ( RF group ) . The control group consisted of 27 patients ( 6 men and 21 women ; age 64 + /- 7 years ) with AF who underwent cardiac surgery during the same period and refused RF ablation .  Mitral valve disease was present in 89 ( 86 % ) and 25 ( 92 % ) patients , respectively ( P = NS ) . RF endocardial ablation was performed in order to obtain isolation of both right and left pulmonary veins , a lesion connecting the previous lines , and a lesion connecting the line encircling the left veins to the mitral annulus . Upon discharge from the hospital , sinus rhythm was present in 65 patients ( 63 % ) versus 5 patients ( 18 % ) in the control group ( P < 0.0001 ) . Mean time of cardiopulmonary bypass was longer in the RF group ( 148 + /- 50 min vs 117 + /- 30 min , P = 0.013 ) . The complication rate was similar in both groups , but RF ablation-related complications occurred in 4 RF group patients ( 3.9 % ) . After a mean follow-up of 12.5 + /- 5 months ( range 4 - 24 ) , 83 ( 81 % ) of 102 RF group patients were in stable sinus rhythm versus 3 ( 11 % ) of 27 in the control group ( P < 0.0001 ) . The success rate was similar among the four surgical centers . Atrial contraction was present in 66 ( 79.5 % ) of 83 patients in the RF group in sinus rhythm . CONCLUSION Endocardial RF left atrial compartmentalization during cardiac surgery is effective in restoring sinus rhythm in many patients . This technique is easy to perform and reproducible . Rare RF ablation-related complications can occur . During follow-up , sinus rhythm persistence is good , and biatrial contraction is preserved in most patients Background —Ablation of the pulmonary veins ( PVs ) for atrial fibrillation treatment is often combined with linear radiofrequency lesions along the left atrium ( LA ) to improve the success rate . The study was design ed to assess the contribution of LA posterior wall isolation to the outcome of circumferential pulmonary vein ablation ( CPVA ) . Methods and Results —CPVA consisted of continuous radiofrequency lesions encircling both ipsilateral PVs plus an ablation line along the mitral isthmus . Patients were then r and omized into 2 groups . In the first group , superior PVs were connected by linear lesions along the LA roof ( CPVA-1 group ) . In the second group , the LA posterior wall was isolated by adding a second line connecting the inferior aspect of the 2 inferior PVs ( CPVA-2 group ) . The study included 120 patients ( 53±11 years , 77 % male , 60 % paroxysmal atrial fibrillation , LA of 41.3±5.4 mm , 46 % with hypertension , and 22 % with structural heart disease ) . After a single ablation procedure and a mean follow-up of 10±4 months , 24 ( 40 % ) patients of the CPVA-1 group had atrial fibrillation recurrences and 3 ( 5 % ) had new-onset LA flutter . In the CPVA-2  group , recurrences were due to atrial fibrillation episodes in 23 patients ( 38 % ) and LA flutter in 4 ( 7 % ) . Freedom from arrhythmia recurrences was not statistically different in the CPVA-1 group as compared with the CPVA-2 group ( log rank P=0.943 ) . Conclusion —Isolation of the LA posterior wall did not increase the success rate of CPVA AIMS A detailed appreciation of the left atrial/pulmonary venous ( LA/PV ) anatomy may be important in improving the safety and success of catheter ablation for AF . The aim of this r and omized study was to determine the impact of computed tomographic ( CT ) integration into an electroanatomic mapping ( EAM ) system on clinical outcome in patients undergoing catheter ablation for atrial fibrillation ( AF ) . METHODS AND RESULTS Eighty patients with AF were r and omized to undergo first-time wide encirclement of ipsilateral PV pairs using EAM alone ( 40 patients ) or with CT ( 40 patients , Cartomerge ) . Wide encirclement of the pulmonary veins was performed using irrigated radiofrequency ablation with the electrophysiological endpoint of electrical isolation ( EI ) . The primary endpoint was single-procedure success at 6 month follow up . Acute and long-term procedural outcomes were also determined . There was no significant difference in single procedure success between EAM ( 56 % ) and cavotricuspid isthmus image ( CTI ) ( 50 % ) groups ( P = 0.9 ) . Acute procedural outcomes ( EI , PV reconnection , sinus rhythm restored by ablation in persistent AF ) , fluoroscopy , and procedure duration s ( EI of right PVs , EI of left PVs , total ) did not differ significantly between EAM and CTI groups . CONCLUSION Image integration to guide catheter ablation for AF did not significantly improve the clinical outcome . Achieving PV EI is the critical determinant of procedural success rather than the mapping tools used to achieve it BACKGROUND In our previous prospect i ve and r and omized study , we have demonstrated that the concomitant surgical ablation using saline-irrigated cooled tip radiofrequency ablation ( SICTRA ) system is more effective than subsequent circumferential pulmonary vein isolation ( CPVI ) combined with substrate modification in treating patients with long-st and ing persistent atrial fibrillation ( LS-AF ) and rheumatic heart disease ( RHD ) undergoing cardiac surgery during middle-term follow-up . Whether this strategy also decreases longer-term arrhythmia recurrence is unknown . This study describes the 4-year efficacy of SICTRA for these patients . Furthermore , we seek to compare the electrophysiological characteristics for recurrent atrial tachyarrhythmia ( ATa ) at the session of catheter ablation between two groups . METHODS Long-term follow-up was performed in 95 patients who underwent the catheter ablation strategy ( n=47 , Group A ) or SICTRA ( n=48 , Group B ) combined with valvular surgery for symptomatic LS-AF patients with RHD . RESULTS After one procedure , Group B had a significantly higher freedom from ATa compared with Group A ( 29/48 vs 15/47 , P=0.005 ) after a mean follow-up of 54 months ( range 48 to 63 months ) . Catheter-based mapping and ablation of recurrent ATa showed larger amounts of macro-reentrant atrial tachycardias ( ATs ) in Group B and higher incidence of pulmonary vein ( PV ) recovery in Group A. After multiple catheter ablations for recurrent ATa , sinus rhythm ( SR ) could be maintained equally between two groups . CONCLUSIONS Single procedure success seems to be higher with SICTRA but repeated catheter ablation potentially results in comparable outcomes in treating patients with LS-AF and RHD during long-term follow-up . More macro-reentrant ATs and more PV recoveries are identified to be responsible for ATa in SICTRA and catheter ablation group , respectively Background —The pulmonary veins ( PVs ) and surrounding ostial areas frequently house focal triggers or reentrant circuits critical to the genesis of atrial fibrillation ( AF ) . We developed an anatomic approach aim ed at isolating each PV from the left atrium ( LA ) by circumferential radiofrequency ( RF ) lesions around their ostia . Methods and Results —We selected 26 patients with resistant AF , either paroxysmal ( n=14 ) or permanent ( n=12 ) . A nonfluoroscopic mapping system was used to generate 3D electroanatomic LA maps and deliver RF energy . Two maps were acquired during coronary sinus and right atrial pacing to vali date the lateral and septal PV lesions , respectively . Patients were followed up closely for ≥6 months . Procedures lasted 290±58 minutes , including 80±22 minutes for acquisition of all maps , and 118±16 RF pulses were deployed . Among 14 patients in AF at the beginning of the procedure , 64 % had sinus rhythm restoration during ablation . PV isolation was demonstrated in 76 % of 104 PVs treated by low peak-to-peak electrogram amplitude ( 0.08±0.02 mV ) inside the circular line and by disparity in activation times ( 58±11 ms ) across the lesion . After 9±3 months , 22 patients ( 85 % ) were AF-free , including 62 % not taking and 23 % taking antiarrhythmic drugs , with no difference ( P = NS ) between paroxysmal and permanent AF . No thromboembolic events or PV stenoses were observed by transesophageal echocardiography . Conclusions —Radiofrequency PV isolation with electroanatomic guidance is safe and effective in either paroxysmal or permanent AF BACKGROUND This r and omized prospect i ve study compared three ablation strategies in patients with long-st and ing persistent atrial fibrillation ( LPeAF ) . It also explored the best procedural endpoint from among the following : circumferential pulmonary vein isolation ( PVI ) + left atrial ( LA ) linear lesions ( roofline , mitral isthmus ) + complex fractionated atrial electrogram ( CFAE ) ablation , PVI + LA linear lesions + cavotricuspid isthmus ( CTI ) ablation + CFAE ablation , and PVI + CFAE ablation . METHODS AND RESULTS A total of 210 patients with LPeAF referred for catheter ablation were enrolled and r and omized into three ablation groups . The patients in group A ( n = 70 ) underwent PVI followed by LA linear and CFAE ablation ; in 93 % of patients the primary endpoint was achieved ( five patients with incomplete linear lesions ) . Of the 70 patients in group B who were subjected to PVI followed by LA linear , CFAE , and CTI ablations , in 94 % of patients the primary endpoint was achieved ( four patients with incomplete linear lesions ) . All patients in group C ( n = 70 ) successfully underwent PVI and CFAE ablation . Direct current cardioversion was performed upon PVI , CFAE elimination , and completion of linear lesions . Patients were followed-up for atrial tachyarrhythmia recurrence for at least 24 months . After a single ablation procedure , group C ( 36 % ) exhibited the lowest success compared with group A ( 54 % ) and group B ( 51 % ) ( P = 0.06 ) . At the mean follow-up of 32 ± 9 months after the final ablation procedure , 53 patients ( 76 % ) in group A , 53 ( 76 % ) in group B , and 41 ( 59 % ) in group C were in sinus rhythm without antiarrhythmic drugs ( P = 0.03 ) . CONCLUSIONS In LPeAF , linear lesions in the LA help improve outcome of ablation , additional CTI ablation does not Background —Pulmonary veins ( PVs ) play a pivotal role in initiating and perpetuating  atrial fibrillation ( AF ) . We investigated if PV electrical isolation from the left atrium is required for curing AF . Methods and Result —Fifty-one patients with paroxysmal or persistent AF underwent circumferential radiofrequency ablation of PV ostia performed with an anatomic approach . The end point of the ablation procedure was the recording of low peak-to-peak bipolar potentials ( < 0.1 mV ) inside the lesions . Left atrium pacing was used to assess the conduction between the PVs and the left atrium . During a mean follow-up period of 16.6±3.9 months , 41 patients ( 80.4 % ) were free of atrial arrhythmias . When patients with and without AF recurrence were analyzed , no significant difference was observed in the mean number of PVs in which the ablation end point was reached ( 3.4±1.2 versus 3.7±0.87 ) and PVs isolated ( 1.5±1.4 versus 1.6±1 ) . We noted that , although in 29 of 41 patients ( 71 % ) without AF recurrence , the ablation end point was reached in all PVs mapped , it was only possible to demonstrate the isolation of all PVs mapped in 2 patients . On the other h and , in 7 of 10 patients ( 70 % ) with AF recurrence , the ablation end point was reached in all PVs mapped , whereas one patient had all PVs isolated . Conclusions —Our findings show that with the use of a pure anatomic approach , it is possible to prevent AF in > 80 % of patients undergoing catheter ablation . Moreover , the isolation of PVs is not crucial for curing AF Background —Electric isolation of the pulmonary veins and posterior left atrium with a single ring of radiofrequency lesions ( single-ring isolation [ SRI ] ) may result in fewer atrial fibrillation ( AF ) recurrences than wide antral pulmonary vein isolation ( wide antral isolation [ WAI ] ) by abolishing extravenous AF triggers . The effect of mitral isthmus line ( MIL ) ablation on outcomes after SRI has not previously been assessed . Methods and Results —We r and omly assigned 220 consecutive patients ( 58±10 years old ; 82 % men ) with highly symptomatic AF ( 61 % paroxysmal , 39 % persistent/longst and ing persistent ) to undergo either SRI or WAI .  Half of each cohort was also r and omly allocated to have left lateral MIL ablation ( 2 × 2 factorial study design ) . Patients were followed clinical ly and with 7-day Holter studies for arrhythmia recurrences . The primary end points were recurrence of AF and organized atrial tachyarrhythmias . AF-free survival at 2 years was better after SRI ( 74 % [ 95 % CI , 65%–82 % ] ) than WAI ( 61 % [ 51%–70 % ] ; P=0.031 ) . Organized atrial tachyarrhythmia – free survival was similar after SRI and WAI ( 67 % [ 57%–75 % ] ersus 64 % [ 54%–72 % ] , respectively , at 2 years ; P=0.988 ) . MIL ablation result ed in better 2-year organized atrial tachyarrhythmia – free survival ( 71 % [ 62%–79 % ] versus 60 % [ 50%–69 % ] ; P=0.07 ) , which approached statistical significance . Survival free of any atrial arrhythmia after one procedure was not significantly affected by isolation technique or MIL ablation . Conclusions —SRI result ed in fewer AF recurrences compared with WAI on long-term follow-up but did not reduce the recurrence of all atrial arrhythmias . MIL ablation may reduce organized atrial tachyarrhythmia recurrences . Clinical Trial Registration —http://www.anzctr.org.au ; ACTRN12606000467538 BACKGROUND We conducted a r and omized , controlled trial of circumferential pulmonary-vein ablation for the treatment of chronic atrial fibrillation . METHODS A total of 146 patients with a mean ( + /-SD ) age of 57+/-9 years who had chronic atrial fibrillation were r and omly assigned to receive amiodarone and undergo two cardioversions during the first three months alone ( the control group ) or in combination with circumferential pulmonary-vein ablation . Cardiac rhythm was assessed with daily telephonic transmissions for one year . The left atrial diameter and the severity of symptoms were assessed at 12 months . RESULTS Among the 77 patients assigned to undergo circumferential pulmonary-vein ablation , ablation was repeated because of recurrent atrial fibrillation in 26 percent of patients and atypical atrial flutter in 6 percent . An intention-to-treat analysis showed that 74 percent of patients in the ablation group and 58 percent of those in the control group were free of recurrent atrial fibrillation or flutter without antiarrhythmic-drug therapy at one year ( P=0.05 ) . Among the 69 patients in the control group , 53 ( 77 percent ) crossed over to undergo circumferential pulmonary-vein ablation for recurrent atrial fibrillation by one year and only 3 ( 4 percent ) were in sinus rhythm without antiarrhythmic-drug therapy or ablation . There were significant decreases in the left atrial diameter ( 12+/-11 percent , P<0.001 ) and the symptom severity score ( 59+/-21 percent , P<0.001 ) among patients who remained in sinus rhythm after circumferential pulmonary-vein ablation . Except for atypical atrial flutter , there were no complications attributable to circumferential pulmonary-vein ablation . CONCLUSIONS Sinus rhythm can be maintained long term in the majority of patients with chronic atrial fibrillation by means of circumferential pulmonary-vein ablation independently of the effects of antiarrhythmic-drug therapy , cardioversion , or both . The maintenance of sinus rhythm is associated with a significant decrease in both the severity of symptoms and the left atrial diameter Background — Catheter ablation ( CA ) and minimally invasive surgical ablation ( SA ) have become accepted therapy for antiarrhythmic drug – refractory atrial fibrillation . This study describes the first r and omized clinical trial comparing their efficacy and safety during a 12-month follow-up . Methods and Results — One hundred twenty-four patients with antiarrhythmic drug – refractory atrial fibrillation with left atrial dilatation and hypertension ( 42 patients , 33 % ) or failed prior CA ( 82 patients , 67 % ) were r and omized to CA ( 63 patients ) or SA ( 61 patients ) . CA consisted of linear antral pulmonary vein isolation and optional additional lines . SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein , ganglionated plexi ablation , and left atrial appendage excision with optional additional lines . Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording . The primary end point , freedom from left atrial arrhythmia > 30 seconds without antiarrhythmic drugs after 12 months , was 36.5 % for CA and 65.6 % for SA ( P=0.0022 ) . There was no difference in effect for subgroups , which was consistent at both sites . The primary safety end point of significant adverse events during the 12-month follow-up was significantly higher for SA than for CA ( n=21 [ 34.4 % ] versus n=10 [ 15.9 % ] ; P=0.027 ) , driven mainly by procedural complications such as pneumothorax , major bleeding , and the need for pacemaker . In the CA group , 1 patient died at 1 month of subarachnoid hemorrhage . Conclusion — In atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation CA , SA is superior to CA in achieving freedom from left atrial arrhythmias after 12 months of follow-up , although the procedural adverse event rate is significantly higher for SA than for CA . Clinical Trial Registration — URL : http:// clinical trials.gov . Unique identifier : NCT00662701 Background — Together with pulmonary veins , many extrapulmonary vein areas may be the source of initiation and maintenance of atrial fibrillation . The left atrial appendage ( LAA ) is an underestimated site of initiation of atrial fibrillation . Here , we report the prevalence of triggers from the LAA and the best strategy for successful ablation . Methods and Results — Nine hundred eighty-seven consecutive patients ( 29 % paroxysmal , 71 % nonparoxysmal ) undergoing redo catheter ablation for atrial fibrillation were enrolled . Two hundred sixty-six patients ( 27 % ) showed firing from the LAA and became the study population . In 86 of 987 patients ( 8.7 % ; 5 paroxysmal , 81 nonparoxysmal ) , the LAA was found to be the only source of arrhythmia with no pulmonary veins or other extrapulmonary vein site reconnection . Ablation was performed either with focal lesion ( n=56 ; group 2 ) or to achieve LAA isolation by placement of the circular catheter at the ostium of the LAA guided by intracardiac echocardiography ( 167 patients ; group 3 ) . In the remaining patients , LAA firing was not ablated ( n=43 ; group 1 ) . At the 12±3-month follow-up , 32 patients ( 74 % ) in group 1 had recurrence compared with 38 ( 68 % ) in group 2 and 25 ( 15 % ) in group 3 ( P<0.001 ) . Conclusions — The LAA appears to be responsible for arrhythmias in 27 % of patients presenting for repeat procedures . Isolation of the LAA could achieve freedom from atrial fibrillation in patients presenting for a repeat procedure when arrhythmias initiating from this structure are demonstrated BACKGROUND This prospect i ve multicenter r and omized study aim ed to compare the efficacy of 3 common ablation methods used for longst and ing permanent atrial fibrillation ( AF ) . METHODS A total of 144 patients with longst and ing permanent AF ( median duration 28 months ) were r and omly assigned to circumferential pulmonary vein ablation ( CPVA , group 1 , n = 47 ) , to pulmonary vein antrum isolation ( PVAI , group 2 , n = 48 ) or to a hybrid strategy combining ablation of complex fractionated or rapid atrial electrograms ( CFAE ) in both atria followed by a pulmonary vein antrum isolation ( CFAE + PVAI , group 3 , n = 49 ) . RESULTS Scarring in the left atrium and structural heart disease/hypertension were present in most patients ( 65 % ) . After a mean follow-up of 16 months , 11 % of patients in group 1 , 40 % of patients in group 2 and 61 % of patients in group 3 were in sinus rhythm after one procedure and with no antiarrhythmic drugs ( P < .001 ) . Sinus rhythm maintenance would increase respectively to 28 % ( group 1 ) , 83 % ( group 2 ) , and 94 % ( group 3 ) after 2 procedures and with antiarrhythmic drugs ( AADs , P < .001 ) . The AF terminated during ablation , either by conversion to sinus rhythm or organization into an atrial tachyarrhythmia , in 13 % of patients ( group 1 ) , 44 % ( group 2 ) , and 74 % ( group 3 ) respectively . CFAE alone , performed as the first step of the ablation in group 3 , organized AF in only 1 patient . CONCLUSION In this study , the hybrid AF ablation strategy including antrum isolation and CFAE ablation had the highest likelihood of maintaining sinus rhythm in patients with longst and ing permanent AF . Electrical isolation of the PVs , although inadequate if performed alone , is relevant to achieve long-term sinus rhythm maintenance after ablation . Bi-atrial CFAE ablation had a minimal impact on AF termination during ablation BACKGROUND Persistent and long-st and ing persistent atrial fibrillation ( AF ) often requires extensive and /or repeat radiofrequency ( RF ) ablation procedures . OBJECTIVE The Tailored Treatment of Persistent Atrial Fibrillation ( TTOP-AF ) study assessed the effectiveness and safety of the phased RF system in a r and omized controlled comparison of medical therapy against phased RF ablation for the management of persistent and long-st and ing persistent AF . METHODS Patients who had failed at least 1 antiarrhythmic drug ( AAD ) were r and omized ( 2:1 ) to ablation management ( AM ) or medical management ( MM ) . AM patients were allowed up to 2 ablations . Index and retreatment procedures consisted of pulmonary vein isolation and ablation of complex fractionated atrial electrograms . MM patients received AAD changes and /or cardioversion . The primary end points of the TTOP-AF study included chronic effectiveness and safety at 6 months and acute safety within 7 days of ablation . RESULTS At 6 months , a greater proportion of AM patients achieved effectiveness off AAD ( 77 of 138 [ 55.8 % ] ) compared to MM patients ( 19 of 72 [ 26.4 % ] ) ( P < .0001 ) . Acutely , 92.8 % ( 128/138 ) of the procedures were successful while 12.3 % ( 17/138 ) experienced a serious procedure and /or device-related adverse event . The predefined acute safety end point was not met . The proportion of patients with chronic safety events did not differ significantly between groups . CONCLUSIONS Catheter ablation of persistent/long-st and ing persistent AF with the phased RF ablation system is effective with greater reduction of AF compared with MM . More intense anticoagulation strategies , careful attention to catheter placement relative to the pulmonary vein ostia , and elimination of electrode interaction are expected to reduce the risk of stroke , pulmonary vein stenosis , and asymptomatic cerebral emboli Summary Background Evidence from animal and human studies suggests that cryoablation might be associated with a lesser inflammatory response and activation of coagulation compared with radiofrequency ablation . The study was aim ed at comparing the effect of cryoballoon and radiofrequency catheter ablation of paroxysmal atrial fibrillation on markers of myocardial damage , inflammation , and activation of coagulation . Methods Forty-one patients received either cryoballoon  ( n = 23 ) or radiofrequency ( n = 18 ) ablation of atrial fibrillation .  We measured troponin I , high-sensitivity CRP , and interleukin 6 at baseline from the cubital vein , and from the right and left atrium before and after ablation , and from the cubital vein the following day . Prothrombin fragments 1 + 2 , soluble P‑selectin , and D‑dimer were measured before and after ablation from both atria . Results We observed higher troponin I release in the cryoballoon than in the radiofrequency group ( 7.01 mcg/l ( interquartile range [ IQR ] : 5.30–9.09 ) vs 2.32 mcg/l ( IQR : 1.45–2.98 ) , p < 0.001 ) . The levels of inflammatory markers ( high-sensitivity CRP and interleukin 6 ) in the two groups were comparable , as were the levels of markers of coagulation activation . Procedure duration , fluoroscopy times , and mid-term success ( 23 months , IQR 7–32 ) of the two groups were also comparable . Conclusions Cryoballoon ablation of atrial fibrillation causes more significant myocardial damage , that is , more extensive ablation lesions , compared with radiofrequency catheter ablation . However , no major differences between these two ablation techniques with regard to the inflammatory response and activation of the coagulation system were observed
Contribution This systematic review found that radiofrequency ablation after a failed drug course maintained sinus rhythm more often than continuation of drug therapy alone .
The benefits of maintaining sinus rhythm with antiarrhythmic drugs appeared to be offset by the serious adverse effects of the drugs .
Context Is radiofrequency catheter ablation a better alternative than medical therapy for patients with atrial fibrillation ?
The Editors Atrial fibrillation is the most common sustained arrhythmia in clinical practice ( 1 ) .
Its prevalence increases with age , from 0.1 % in people younger than 55 years to more than 9 % by 80 years of age ( 2 ) .
The heavy burden of atrial fibrillation on morbidity , mortality , and health care re sources creates a pressing need for novel approaches to management .
In some patients , adequate pharmacologic slowing of the ventricular response rate ( a rate-control strategy ) is sufficient to control symptoms .
However , many patients remain symptomatic from the lack of organized atrial contraction and the persistent irregularity of the ventricular response in atrial fibrillation .
In such patients , the appropriate treatment is restoration of normal sinus rhythm , achieved electrically or chemically ( a rhythm-control strategy ) ( 2 ) .
Radiofrequency catheter ablation is a promising approach that offers the benefits of maintaining sinus rhythm without the adverse effects of antiarrhythmic drugs .
Catheter ablation for atrial fibrillation is based on the underst and ing that electrical activity emanating from the pulmonary veins frequently serves as a trigger for atrial fibrillation .
In the late 1990s , Hassaguerre and colleagues ( 5 ) observed that elimination of local electrograms at these foci with radiofrequency energy reduced the risk for recurrence of atrial fibrillation .
Currently , the foundation of most atrial fibrillation ablation procedures is to target and electrically isolate the pulmonary veins ( 6 ) .
This may be achieved by delivering lesions immediately outside the ostia of the pulmonary veins or along a wider area in the left atrium encircling the veins .
Additional lesion sets have been used to ablate nonpulmonary vein triggers of atrial fibrillation and to target atrial areas thought to be responsible for maintaining atrial fibrillation ( 6 ) .
These linear lesions may be created in the posterior left atrium , the roof of the left atrium , the interatrial septum , and the isthmus formed between the mitral annulus and the pulmonary vein or left atrial appendage .
At present , the Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation , put forth by the Heart Rhythm Society and endorsed by several professional organizations , states that the foundation of most atrial fibrillation ablation procedures is to target the pulmonary veins , pulmonary vein antra , or both ( 6 ) .
The panel advised us that 8-mmtip and irrigated-tip catheters are now the catheters of choice for radiofrequency ablation of atrial fibrillation in the United States .
The conventional 4-mmtip catheter is rapidly being phased out of use for this indication .
The following 3 key questions were formulated : 1 .
What is the effect of radiofrequency catheter ablation on short-term ( 6 to 12 months ) and long-term ( > 12 months ) rhythm control ; rates of congestive heart failure ; changes in the size of the left atrium and ventricle ; rates of stroke ; quality of life ; avoiding anticoagulation ; and readmissions for paroxysmal , persistent , and long-st and ing persistent ( chronic ) atrial fibrillation ?
2 .
How does the effect of radiofrequency ablation  on rhythm control differ among the various techniques used ?
3 .
What are the short- and long-term complications and harms associated with radiofrequency ablation ?