Left Atrial Appendage Isolation in Patients Not Responding to Pulmonary Vein Isolation
Authors: Christian-Hendrik Heeger, Andreas Rillig, Dominic Geisler, Peter Wohlmuth, Thomas Fink, Shibu Mathew, Roland Richard Tilz, Bruno Reissmann, Christine Lemes, Tilman Maurer, Francesco Santoro, Osamu Inaba, Christian Sohns, YinHao Huang, Hannes Alessandrini, Inge Dotz, Michael Schlüter, Andreas Metzner, Karl-Heinz Kuck, Feifan Ouyang
Journal: Circulation (2019)

◼ catheter ablation ◼ stroke ◼ thrombosis P ulmonary vein isolation (PVI) is an effective strategy for patients with paroxysmal atrial fibrillation (AF). 1 However, in patients with persistent AF and long-standing persistent AF, PVI is associated with limited success, with patients not responding to PVI. 2 Recently, the BELIEF trial (Effect of Empirical Left Atrial Appendage Isolation on Long-term Procedure Outcome in Patients With Persistent or Longstanding Persistent Atrial Fibrillation Undergoing Catheter Ablation) showed that an electric isolation of the left atrial (LA) appendage (LAA) in addition to PVI could increase clinical success. 3Although potentially effective, this strategy causes electromechanical dissociation of the LAA and was assumed to be associated with increased risk for LAA thrombus and thromboembolism. 4We sought to investigate the incidence of LAA thrombus and thromboembolism and the impact of LAA closure on the prevention of thromboembolic events, in addition to the clinical benefit after left atrial appendage isolation (LAAI).One hundred sixteen patients with AF or atrial tachycardia and LAAI were prospectively enrolled (LAAI group).LAAI was achieved by PVI, linear lesions, and substrate modifications after a median of 2 failed ablation procedures.The patients were compared with a control group of 116 patients with recurrent AF or atrial tachycardia after ≥1 failed AF ablation with PVI, linear lesions, and substrate modifications but without LAAI.The control group was identified by propensity score matching (variables included age, sex, arterial hypertension, diabetes mellitus type II, coronary artery disease, CHA 2 DS 2 -VASc score, LA diameter, and AF type) from our institutional long-term follow-up database (n=551).All subjects gave written informed consent.The study was approved by the institutional review board and was performed in accordance with the Declaration of Helsinki.Our ablation strategies have been described in detail before. 2,5All patients underwent transesophageal echocardiography before the procedure.LAAI was the result of achieving bidirectional block of an anterior and a mitral isthmus line aiming to treat LA macro-reentrant tachycardia or documented localized reentrant atrial tachycardia originating near the LAA base, or it was the result of extensive ablation of complex fractionated atrial electrograms at the anterior LA and mitral isthmus.LAAI was achieved by linear ablation in 104 patients (90%).In 12 patients (10%), the LAA was isolated during extensive ablation of complex fractionated atrial electrograms at the anterior wall and the LA isthmus.Lifelong oral anticoagulation (OAC) was strongly recommended to all patients undergoing LAAI.For control group patients, OAC was continued for ≥3 months.Afterward, OAC was recommended on the basis of the patient's CHA 2 DS 2 -VASc score.ECGs and Holter ECG recordings were performed in our outpatient clinic or by the referring physician on day 1 after procedure; at 1, 3, and 6 months; and at 6-month intervals thereafter.