Catheter ablation for paroxysmal atrial fibrillation (AF) is becoming increasingly
common, particularly as success rates improve. In this population, pulmonary vein
(PV) isolation (PVI) is the cornerstone of therapy.
1
,
2
However, in patients with persistent AF, the optimal lesion set has not been determined.
While small studies have demonstrated that additional ablation beyond PVI is associated
with decreased AF recurrence, randomized data have not corroborated this notion.
3
,
4
,
- Tamborero D.
- Mont L.
- Berruezo A.
- Matiello M.
- Benito B.
- Sitges M.
- Vidal B.
- de Caralt T.M.
- Perea R.J.
- Vatasescu R.
- Brugada J.
Left atrial posterior wall isolation does not improve the outcome of circumferential
pulmonary vein ablation for atrial fibrillation: a prospective randomized study.
Circ Arrhythm Electrophysiol. 2009; 2: 35-40
5
The combination of PVI and posterior wall isolation (PWI) is an attractive lesion
set for a number of reasons. First, data from the surgical literature suggest that
isolation of the “box” between the PVs in the posterior wall of the left atrium (LA)
is associated with improved outcomes.
6
Second, PWI creates conduction block to prevent potential reentrant circuits. Third,
PWI “reinforces” PVI by reducing the potential for small gaps in the posterior aspect
of the PVI lesion set that lead to PV conduction recovery. Fourth, PWI debulks the
potential substrate or trigger sites for AF initiation or perpetuation, as the posterior
wall has been shown to be histologically similar to PV tissue.
7
,
8
Finally, PWI may more reliably lead to ablation of ganglionated plexi.To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Heart RhythmAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins.N Engl J Med. 1998; 339: 659-666
- 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.Heart Rhythm. 2017; 14: e275-e444
- Approaches to catheter ablation for persistent atrial fibrillation.N Engl J Med. 2015; 372: 1812-1822
- Left atrial posterior wall isolation does not improve the outcome of circumferential pulmonary vein ablation for atrial fibrillation: a prospective randomized study.Circ Arrhythm Electrophysiol. 2009; 2: 35-40
- Does isolation of the left atrial posterior wall improve clinical outcomes after radiofrequency catheter ablation for persistent atrial fibrillation? A prospective randomized clinical trial.Int J Cardiol. 2015; 181: 277-283
- Isolating the entire posterior left atrium improves surgical outcomes after the Cox maze procedure.J Thorac Cardiovasc Surg. 2008; 135: 870-877
- Morphological evidence of muscular connections between contiguous pulmonary venous orifices: relevance of the interpulmonary isthmus for catheter ablation in atrial fibrillation.Heart Rhythm. 2009; 6: 1192-1198
- Left atrial anatomy revisited.Circ Arrhythm Electrophysiol. 2012; 5: 220-228
- Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation.N Engl J Med. 2016; 374: 2235-2245
- Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation.Europace. 2017; 19: 1109-1115
- Posterior wall isolation using the cryoballoon in conjunction with pulmonary vein ablation is superior to pulmonary vein isolation alone in patients with persistent atrial fibrillation: a multicenter experience.Heart Rhythm. 2018; 15: 1121-1129
- Atrioesophageal fistula formation with cryoballoon ablation is most commonly related to the left inferior pulmonary vein.Heart Rhythm. 2017; 14: 184-189
- Esophageal injury and atrioesophageal fistula caused by ablation for atrial fibrillation.Circulation. 2017; 136: 1247-1255
Article info
Footnotes
Dr Michaud has received honoraria for lectures from Abbott, Biotronik, Biosense Webster, Medtronic, and Boston Scientific. Dr Richardson reports no conflict of interest.
Identification
Copyright
© 2018 Heart Rhythm Society. All rights reserved.
