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How to perform left atrial appendage electrical isolation using radiofrequency ablation

      Although pulmonary vein (PV) isolation (PVI) has been considered an effective treatment for paroxysmal atrial fibrillation (AF), non-paroxysmal AF is a complex arrhythmia for which no ablation strategy has been demonstrated to be effective and widely accepted. As such, a success rate of ∼55% in these patients with AF (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial Part II [Star AF II trial]) is not acceptable in our opinion and efforts should be made to seek for alternative strategies. A significant role of the left atrial appendage (LAA) in AF arrhythmogenesis has been described, with several studies reporting a substantial incremental benefit of LAA electrical isolation (LAAEI) in addition to standard ablation.

      Romero J, Michaud GF, Avendano R, et al. Benefit of left atrial appendage electrical isolation for persistent and long-standing persistent atrial fibrillation: a systematic review and meta-analysis. Europace. 2018 Jan 12. https://doi.org/10.1093/europace/eux372 [Epub ahead of print].

      Herein, we describe in detail different techniques used to isolate this structure in an effective and safe manner using radiofrequency (RF) ablation (RFA), with special emphasis on localization of the left phrenic nerve (LPN) and left circumflex (LCx) coronary artery before RFA delivery. Parameters used during ablation are also described, given that high-power lesions are usually required to obtain complete and permanent isolation of this structure. Special consideration on postprocedural oral anticoagulation treatments is also reviewed in the Supplement.

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      References

      1. Romero J, Michaud GF, Avendano R, et al. Benefit of left atrial appendage electrical isolation for persistent and long-standing persistent atrial fibrillation: a systematic review and meta-analysis. Europace. 2018 Jan 12. https://doi.org/10.1093/europace/eux372 [Epub ahead of print].

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