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How to perform encircling ablation of the left atrium

      The purpose of this article is to describe the technique and results of circumferential pulmonary vein ablation (CPVA) in patients with atrial fibrillation (AF) as currently performed in Milan.
      • Pappone C.
      • Rosanio S.
      • Oreto G.
      • Tocchi M.
      • Gugliotta F.
      • Vicedomini G.
      • Salvati A.
      • Dicandia C.
      • Mazzone P.
      • Santinelli V.
      • Gulletta S.
      • Chierchia S.
      Circumferential radiofrequency ablation of PV ostia.
      • Pappone C.
      • Oreto G.
      • Rosanio S.
      • Vicedomini G.
      • Tocchi M.
      • Gugliotta F.
      • Salvati A.
      • Dicandia C.
      • Calabro M.P.
      • Mazzone P.
      • Ficarra E.
      • Di Gioia C.
      • Gulletta S.
      • Nardi S.
      • Santinelli V.
      • Benussi S.
      • Alfieri O.
      Atrial electroanatomic remodeling after circumferential radiofrequency PV ablation Efficacy of an anatomic approach in a large cohort of patients with AF.
      • Pappone C.
      • Rosanio S.
      • Augello G.
      • Gallus G.
      • Vicedomini G.
      • Mazzone P.
      • Gulletta S.
      • Gugliotta F.
      • Pappone A.
      • Santinelli V.
      • Tortoriello V.
      • Sala S.
      • Zangrillo A.
      • Crescenzi G.
      • Benussi S.
      • Alfieri O.
      Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study.
      • Pappone C.
      • Manguso F.
      • Vicedomini G.
      • Gugliotta F.
      • Santinelli O.
      • Ferro A.
      • Gulletta S.
      • Sala S.
      • Sora N.
      • Paglino G.
      • Augello G.
      • Agricola E.
      • Zangrillo A.
      • Alfieri O.
      • Santinelli V.
      Prevention of iatrogenic atrial tachycardia after ablation of atrial fibrillation A prospective randomized study comparing circumferential pulmonary vein ablation with a modified approach.
      • Pappone C.
      • Santinelli V.
      • Manguso F.
      • Vicedomini G.
      • Gugliotta F.
      • Augello G.
      • Mazzone P.
      • Tortoriello W.
      • Landoni G.
      • Zangrillo A.
      • Lang C.
      • Tomita T.
      • Mesas C.
      • Mastella E.
      • Alfieri O.
      PV denervation enhances long-term benefit after circumferential ablation for paroxysmal AF.
      • Pappone C.
      • Santinelli V.
      The who, what, why, and how-to guide for circumferential pulmonary vein ablation.
      • Pappone C.
      • Oral H.
      • Santinelli V.
      • Vicedomini G.
      • Lang C.C.
      • Manguso F.
      • Torracca L.
      • Benussi S.
      • Alfieri O.
      • Hong R.
      • Lau W.
      • Hirata K.
      • Shikuma N.
      • Hall B.
      • Morady F.
      Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of AF.
      • Pappone C.
      • Santinelli V.
      Atrial fibrillation ablation: state of the art.
      • Pappone C.
      • Santinelli V.
      Atrial fibrillation ablation: a realistic alternative to pharmacologic therapy.
      • Pappone C.
      • Santinelli V.
      Towards a unified strategy for atrial fibrillation ablation?.
      • Lang C.C.
      • Santinelli V.
      • Augello G.
      • Ferro A.
      • Gugliotta F.
      • Gulletta S.
      • Vicedomini G.
      • Mesas C.
      • Paglino G.
      • Sala S.
      • Sora N.
      • Mazzone P.
      • Manguso F.
      • Pappone C.
      Transcatheter radiofrequency ablation of atrial fibrillation in patients with mitral valve prostheses and enlarged atria: safety, feasibility, and efficacy.
      • Mesas C.E.
      • Pappone C.
      • Lang C.C.
      • Gugliotta F.
      • Tomita T.
      • Vicedomini G.
      • Sala S.
      • Paglino G.
      • Gulletta S.
      • Ferro A.
      • Santinelli V.
      Left atrial tachycardia after circumferential pulmonary vein ablation for atrial fibrillation: electroanatomic characterization and treatment.
      • Pappone C.
      • Vicedomini G.
      • Manguso F.
      • Gugliotta F.
      • Mazzone P.
      • Gulletta S.
      • Sora N.
      • Sala S.
      • Marci A.
      • Augello G.
      • Rivolsi L.
      • Santagostino A.
      • Santinelli V.
      Robotic magnetic navigation for atrial fibrillation ablation.
      • Lang C.C.
      • Gugliotta F.
      • Santinelli V.
      • Mesas C.
      • Tomita T.
      • Vicedomini G.
      • Augello G.
      • Gulletta S.
      • Mazzone P.
      • De Cobelli F.
      • Del Maschio A.
      • Pappone C.
      Endocardial impedance mapping during circumferential pulmonary vein ablation of atrial fibrillation differentiates between atrial and venous tissue.
      Since a significant learning curve still exists with the standard procedure, we have recently developed a new system, called remote magnetic navigation and ablation, which can be performed by less experienced operators while at the same time still reducing complications.
      • Pappone C.
      • Vicedomini G.
      • Manguso F.
      • Gugliotta F.
      • Mazzone P.
      • Gulletta S.
      • Sora N.
      • Sala S.
      • Marci A.
      • Augello G.
      • Rivolsi L.
      • Santagostino A.
      • Santinelli V.
      Robotic magnetic navigation for atrial fibrillation ablation.
      The results of our standard technique with manually deflectable catheters are based on about 10,000 patients with paroxysmal, persistent, or permanent AF, many of whom have structural heart disease.
      • Pappone C.
      • Rosanio S.
      • Oreto G.
      • Tocchi M.
      • Gugliotta F.
      • Vicedomini G.
      • Salvati A.
      • Dicandia C.
      • Mazzone P.
      • Santinelli V.
      • Gulletta S.
      • Chierchia S.
      Circumferential radiofrequency ablation of PV ostia.
      • Pappone C.
      • Oreto G.
      • Rosanio S.
      • Vicedomini G.
      • Tocchi M.
      • Gugliotta F.
      • Salvati A.
      • Dicandia C.
      • Calabro M.P.
      • Mazzone P.
      • Ficarra E.
      • Di Gioia C.
      • Gulletta S.
      • Nardi S.
      • Santinelli V.
      • Benussi S.
      • Alfieri O.
      Atrial electroanatomic remodeling after circumferential radiofrequency PV ablation Efficacy of an anatomic approach in a large cohort of patients with AF.
      • Pappone C.
      • Rosanio S.
      • Augello G.
      • Gallus G.
      • Vicedomini G.
      • Mazzone P.
      • Gulletta S.
      • Gugliotta F.
      • Pappone A.
      • Santinelli V.
      • Tortoriello V.
      • Sala S.
      • Zangrillo A.
      • Crescenzi G.
      • Benussi S.
      • Alfieri O.
      Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study.
      • Pappone C.
      • Manguso F.
      • Vicedomini G.
      • Gugliotta F.
      • Santinelli O.
      • Ferro A.
      • Gulletta S.
      • Sala S.
      • Sora N.
      • Paglino G.
      • Augello G.
      • Agricola E.
      • Zangrillo A.
      • Alfieri O.
      • Santinelli V.
      Prevention of iatrogenic atrial tachycardia after ablation of atrial fibrillation A prospective randomized study comparing circumferential pulmonary vein ablation with a modified approach.
      • Pappone C.
      • Santinelli V.
      • Manguso F.
      • Vicedomini G.
      • Gugliotta F.
      • Augello G.
      • Mazzone P.
      • Tortoriello W.
      • Landoni G.
      • Zangrillo A.
      • Lang C.
      • Tomita T.
      • Mesas C.
      • Mastella E.
      • Alfieri O.
      PV denervation enhances long-term benefit after circumferential ablation for paroxysmal AF.
      • Pappone C.
      • Santinelli V.
      The who, what, why, and how-to guide for circumferential pulmonary vein ablation.
      • Pappone C.
      • Oral H.
      • Santinelli V.
      • Vicedomini G.
      • Lang C.C.
      • Manguso F.
      • Torracca L.
      • Benussi S.
      • Alfieri O.
      • Hong R.
      • Lau W.
      • Hirata K.
      • Shikuma N.
      • Hall B.
      • Morady F.
      Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of AF.
      • Pappone C.
      • Santinelli V.
      Atrial fibrillation ablation: state of the art.
      • Pappone C.
      • Santinelli V.
      Atrial fibrillation ablation: a realistic alternative to pharmacologic therapy.
      • Pappone C.
      • Santinelli V.
      Towards a unified strategy for atrial fibrillation ablation?.
      • Lang C.C.
      • Santinelli V.
      • Augello G.
      • Ferro A.
      • Gugliotta F.
      • Gulletta S.
      • Vicedomini G.
      • Mesas C.
      • Paglino G.
      • Sala S.
      • Sora N.
      • Mazzone P.
      • Manguso F.
      • Pappone C.
      Transcatheter radiofrequency ablation of atrial fibrillation in patients with mitral valve prostheses and enlarged atria: safety, feasibility, and efficacy.
      • Mesas C.E.
      • Pappone C.
      • Lang C.C.
      • Gugliotta F.
      • Tomita T.
      • Vicedomini G.
      • Sala S.
      • Paglino G.
      • Gulletta S.
      • Ferro A.
      • Santinelli V.
      Left atrial tachycardia after circumferential pulmonary vein ablation for atrial fibrillation: electroanatomic characterization and treatment.
      At present, remote magnetic navigation and ablation has been performed safely in about 200 patients with paroxysmal, persistent, or permanent AF.
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