Epicardial Approach in Recurred Atrial Fibrillation
Condition: Persistent Atrial Fibrillation
MeSH terms: Atrial Fibrillation
Study type: Interventional

Summary: 
      We aimed to assess the benefit of epicardial mapping and ablation in patients with recurred
      atrial tachyarrhythmias after single procedure for atrial fibrillation. We hypothesize that
      both endocardial and epicardial approach is superior to only endocardial approach with
      regards to clinical recurrence. Participants are randomized into a hybrid approach or an
      endocardial approach.
    

Detailed description: 
      Atrial electrical activity during atrial fibrillation depends on the distribution of
      myocardial tissue. Circumferential and longitudinal muscular bundles are multi-level crossing
      across the entire thickness of atrial wall. At radiofrequency catheter ablation for atrial
      fibrillation, transmural lesions are important to reduce the arrhythmogenic substrates and to
      prevent recurrence of scar-related atrial tachyarrhythmias.

      Radiofrequency ablation applying electric current depends on impedance between patch and the
      tip electrode of a catheter. Increased impedance results in increased tissue heating,
      following an irreversible damage. However, overheating limits to create deep lesion formation
      because an increased impedance impedes the energy delivery to tissue. Furthermore, prolonged
      ablation time may result in severe complications, such as steam pop, cardiac perforation, and
      char formation. Therefore, both endocardial and epicardial ablations may be more effective to
      create a transmural lesion compared with only endocardial ablation.

      Organized atrial tachycardia is common in patient who underwent ablation for atrial
      fibrillation. Activation mapping for atrial tachycardia is critical for ablating an isthmus.
      However, when the amplitude of endocardial potentials after previous ablations is decreased
      as system does not detect, summation of data from endocardium may give us wrong information
      about atrial tachycardia. Data from epicardial potential during tachycardia may be helpful to
      terminate a tachycardia.

      We aimed to assess the benefit of epicardial mapping and ablation in patients with recurred
      atrial tachyarrhythmias after single procedure for atrial fibrillation. We hypothesize that
      both endocardial and epicardial approach is superior to only endocardial approach with
      regards to clinical recurrence. Participants are randomized into a hybrid approach or an
      endocardial approach.
    

Intervention name(s): hybrid approach; conventional endocardial approach
Intervention type(s): Procedure; Procedure
Intervention description(s): Before transseptal puncture, epicardial puncture is performed through subxyphoid approach. Atrial epicardial potentials are recorded using multi-electrode catheter, leading an activation map for atrial tachycardia and map for continuous fractionated atrial electrograms during atrial fibrillation. Endocardial potentials are also recorded in the same fashion. Procedural endpoint is a tachycardia termination or a noninducibility of tachycardia.; Atrial endocardial potentials are recorded using multi-electrode catheter, leading an activation map for atrial tachycardia and map for continuous fractionated atrial electrograms during atrial fibrillation. Procedural endpoint is a tachycardia termination or a noninducibility of tachycardia.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: persistent atrial fibrillation; catheter ablation; epicardial mapping and ablation