Hands On
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.When and how to target atrial fibrillation sources outside the pulmonary veins: A practical approach
Pulmonary vein (PV) isolation is an effective procedure in patients with paroxysmal atrial fibrillation (AF). For most patients with persistent AF and a subset of patients with paroxysmal AF, however, PV isolation may not be sufficient. Patients with the persistent form are more often beleaguered with comorbidities, which result in a greater degree of structural alterations that contribute to the maintenance of AF. In addition, the atrial activation rate during AF is higher (as evidenced by a shorter AF cycle length) in patients with persistent AF, consistent with a greater degree of electrical remodeling.Fluoroless catheter ablation of atrial fibrillation
Although the concept of performing fluoroless catheter ablation of atrial fibrillation (AF) was introduced several years ago, it has yet to gain wide adoption.1,2 Despite its well-documented advantages, there are several impediments, including concern that a fluoroless approach will add time to the procedure and may require a second operator. However, perhaps the greatest obstacle is that many electrophysiologists are trained to rely on fluoroscopic imaging and are therefore reluctant to trust intracardiac echocardiography (ICE) as their primary visual modality for tracking catheter movement and manipulation.Pulmonary vein signal interpretation during cryoballoon ablation for atrial fibrillation
The recognition that paroxysmal atrial fibrillation (AF) is predominantly triggered by ectopic beats arising from the vicinity of pulmonary veins (PVs) has spurred the establishment of percutaneous procedures specifically designed to electrically sequestrate the arrhythmogenic PV from the vulnerable left atrium (LA) substrate.1 Recently, the procedure has evolved with the development of purpose-built pulmonary vein isolation (PVI) tools, such as the cryoballoon catheter. This article discusses the anatomic and electrophysiologic bases for the interpretation of pulmonary vein potentials (PVPs) using a small-caliber circular mapping catheter (CMC) and provides an expanded discussion on the pacing maneuvers relevant to cryoballoon-based PVI procedures.Safety and feasibility of transseptal puncture for atrial fibrillation ablation in patients with atrial septal defect closure devices
AF is often found in association with an ASD.1–4 There are an increasing number of patients undergoing transcatheter closure of an ASD who subsequently develop AF in clinical practice.2–4 Catheter ablation has emerged as an effective treatment strategy for drug-refractory symptomatic AF.5 While transseptal access to the left atrium (LA) is a prerequisite for AF ablation, it may prove difficult in the presence of an ASD closure device.6,7 Anticipating technical difficulties and potential complications may discourage operators from considering catheter ablation of AF in this particular patient population.How to perform and interpret rotational angiography in the electrophysiology laboratory
Sophisticated imaging methods have been growing in popularity since the introduction of curative ablation procedures for atrial fibrillation (AF). This trend is predicated on the need for a precise anatomic guidance within the complex left atrial (LA) anatomy and less reliance on electrocardiographic characteristics of the substrate. Traditional two-dimensional imaging methods such as fluoroscopy would not satisfy the needs of a complex catheter navigation inside three-dimensional (3D) anatomic structures that may not be confined to the radiographic cardiac silhouette (e.g., pulmonary veins [PVs]).How to perform linear lesions
Atrial fibrillation (AF) is a particularly complex arrhythmia because the mechanisms leading to fibrillation are not fully understood. Accordingly, ablation strategies have evolved largely on an empirical basis. The creation of linear lesions is a fundamental strategy that is indispensable to an electrophysiology laboratory performing ablation for treatment of this arrhythmia.How to determine and assess endpoints for left atrial ablation
Studies have demonstrated that myocardium surrounding pulmonary vein (PV) ostia plays an important role in the initiation and perpetuation of atrial fibrillation (AF).1,2 This important finding has led to the development of segmental PV ostial isolation, circumferential ablation, and isolation around the PVs using circular linear lesions guided by three-dimensional (3D) electroanatomic mapping. Substrate modification using limited linear ablation also has been demonstrated to improve the clinical outcome after PV isolation in patients with AF inducibility.
