环肺静脉隔离术对阵发性心房颤动患者左心房大小和功能的影响

目的:探讨环肺静脉隔离术对阵发性心房颤动(Af)患者左心房大小和功能的影响。方法:28例阵发性Af患者择期行环肺静脉隔离术,根据Af复发与否分为复发组(5例)和未复发组(23例);同期选择窦性心律患者30例作为对照组。应用超声心动图对所有患者在窦性心律下于术前、术后24h、1个月和3个月时测量左心房最大容积(LAVmax)、左心房最小容积(LAVmin)、二尖瓣环晚期运动峰值速度(A峰)、肺静脉收缩期波(S峰)、舒张期波(D峰)、心房血流逆向波(PVa峰),并计算左心房射血分数(LAEF)。结果:①左心房大小:复发组和未复发组患者消融术前LAVmax和LAVmin均较对照组增加(均P<0.05),在术后24hLAVmin均增加(均P<0.01),LAVmax无明显变化;未复发组术后1个月时LAVmax、LAVmin均减小至正常(均P<0.05),术后3个月时未再进一步减小,而复发组术后1个月和3个月恢复至术前大小。②左心房功能:复发组和未复发组消融术前LAEF和A峰值均较对照组降低(均P<0.05),术后24h左心房功能指标均较术前明显降低(均P<0.05);术后1个月时复发组和未复发组左心房功能指标较术后24h均明显增加(均P<0.01),2组PVa峰、S峰和D峰值均恢复至术前正常水平(均P<0.05),LAEF和A峰在未复发组增加至正常水平(P<0.05),而在复发组仅恢复至术前水平;术后3个月时左心房功能指标较术后1个月时均未再有明显变化。结论:环肺静脉隔离术可以逆转阵发性Af造成的左心房大小和功能异常,而且长期对左心房大小和功能无负面影响。     

Reduction of P-wave duration and successful pulmonary vein isolation in patients with atrial fibrillation

Introduction: We hypothesize that successful pulmonary vein (PV) isolation can shorten the P-wave duration in patients with atrial fibrillation (AF).
Methods and Results: We recorded magnified surface electrocardiogram (ECG) and P-wave signal-averaged ECG using 12 electrode leads before and after 31 PV isolation procedures in 27 patients with AF. The patients were followed for 16 ± 4 months. Repeat ablation studies documented failed PV isolation in seven patients with AF recurrences. At baseline, the maximal P-wave duration in patients without AF recurrence (161 ± 7 msec) was slightly shorter than that in patients with AF recurrence (168 ± 10 msec, P < 0.05). After ablation, patients without recurrence showed a significant reduction of P-wave duration from 161 ± 7 msec to 151 ± 8 msec (P < 0.0001). In contrast, no change of P-wave duration was noted in patients with recurrences. These findings were confirmed with signal averaged ECG of the P-waves. Three-dimensional (3-D) computer simulation using an atrial cell model showed that elimination of the muscle sleeves inside the PV resulted in a shortening of the P-wave duration and change of the terminal portion of the P-wave morphology.
Conclusions: A significant shortening of P-wave duration by P-wave signal-averaged ECG can be used as an indicator for successful PV isolation. These findings suggest that activation of the PV muscle sleeves may be an important component of the terminal portion of the P-wave on surface ECG.     

Maintenance of atrial fibrillation by pulmonary vein tachycardia with ostial conduction block: evidence of an interpulmonary vein electrical connection

We report a case of a 56-year-old man with paroxysmal atrial fibrillation who underwent segmental, ostial pulmonary vein (PV) isolation while in arrhythmia. During isolation of the left superior PV (LSPV), organized electrical activity was seen within the vein, suggestive of a PV tachycardia with a cycle length of 90 ms. Simultaneously, organized electrical activity with a cycle length of 180 ms was seen in the left inferior PV (LIPV), suggestive of 2:1 conduction between the LSPV and the LIPV. Isolation of the LIPV resulted in conversion to sinus rhythm, while confirming isolation of the LSPV by the presence of ongoing PV tachycardia in this vein. This case demonstrates a direct electrical connection between the ipsilateral left PVs, leading to maintenance of atrial fibrillation.     

Long-term outcome following successful pulmonary vein isolation: pattern and prediction of very late recurrence

Background:  Despite encouraging results of pulmonary vein isolation (PVI) ablation for atrial fibrillation (AF), it is unclear whether there is genuine cure or there is an important attrition rate. We sought to determine the long-term outcome of the initial responders who experienced a prolonged AF-free complete response.
Methods:  From a series of 350 consecutive patients who underwent PVI for AF, 264 patients (75%) (males 71%, age 57 ± 12 years, paroxysmal AF 87%) who demonstrated ≥1 year AF-free follow-up on no antiarrhythmic drugs were followed for 1–5 years.
Results:  During 28 ± 12 months follow-up, 23 of 264 (8.7%) patients had recurrence of AF. The actuarial recurrence at 2 years postablation was 5.8% and increased to 25.5% at 5 years. Compared with long-term responders, more patients with late recurrence had hypertension (HR = 2.18, P = 0.009) and hyperlipidemia (HR = 4.01, P = 0.0005). Among 18 patients with recurrent AF necessitating repeat PVI, 15 (83%) required re-isolation of > 1 PV and 28 of 45 (58%) PVs showed reconnection. All PVs were re-isolated and five (28%) patients had additional linear ablation. All 15 patients became AF-free again.
Conclusions:  Although most patients following PVI remain AF-free, some patients develop "late" recurrence of AF. The "late" recurrence patients are more likely to have hypertension and hyperlipidemia. Most late recurrences are associated with PV reconnections. Our observations emphasize the importance of continued long-term vigilance for AF recurrence, and also raise concerns regarding the need for long-term anticoagulation therapy.     

Spontaneous and induced pulmonary vein tachycardia after pulmonary vein isolation.

A case is reported of recurrence of paroxysmal atrial fibrillation after pulmonary vein ablation. A second procedure achieved isolation of three pulmonary veins and showed persistence of pulmonary vein tachycardia in one with implications concerning the electrophysiology of atrial fibrillation.     

Discrimination of left atrial and pulmonary vein potentials in patients with paroxysmal atrial fibrillation

INTRODUCTION: Ablation of muscular fascicles around the ostium of pulmonary veins (PVs) resulting in electrical isolation of the veins may prove to be an effective treatment for atrial fibrillation (AF). Correctly discriminating atrial and PV potentials is necessary to effectively isolate PVs from the left atrium in patients with paroxysmal AF. METHODS AND RESULTS: A training set of 151 electrode recordings obtained from 10 patients with AF was used to develop an algorithm to discriminate atrial and PV potentials. Bipolar electrograms were collected from a multielectrode basket catheter placed sequentially into each PV. Amplitude, slope, and normalized slopes of both bipolar and quadripolar electrograms (difference between adjacent bipoles) were entered into a binary logistic regression model. A receiver operating characteristic curve was used to define a threshold able to effectively discriminate atrial and PV potentials. The normalized slopes of both domains, bipolar and quadripolar, produced a logistic function that discriminated atrial and PV potentials against a threshold (0.38) with 97.8% sensitivity and 94.9% specificity. The algorithm then was evaluated on a test set of 214 electrode recordings from four patients who also had paroxysmal AF. These patient electrograms also were evaluated by two independent electrophysiologists. The algorithm and electrophysiologists matched identification of activation origin in 84% of electrograms. CONCLUSION: Atrial and PV potentials acquired from a multielectrode basket catheter can be discriminated using the normalized slopes of bipolar and quadripolar electrograms. These additional parameters need to be included by physicians determining the preferential ablation site within PVs.     

Impact of adenosine-provoked acute dormant pulmonary vein conduction on recurrence of atrial fibrillation

Impact of ATP Reconduction on AF Recurrence. Introduction: Adenosine can be associated with acute recovery of conduction to the pulmonary veins (PVs) immediately after isolation. The objective of this study was to evaluate whether the response to adenosine predicts atrial fibrillation (AF) recurrence after a single ablation procedure in patients with paroxysmal AF. Methods and Results: A total of 109 consecutive patients (61 ± 10 years; 91 males) with drug‐refractory paroxysmal AF who underwent AF ablation were analyzed. After PV antrum isolation (PVAI), dormant PV conduction was evaluated by an administration of adenosine in all patients. No acute reconnections were provoked by the adenosine in 70 (64.2%) patients (Group‐1), but they were provoked in at least one side of the ipsilateral PVs in 39 (35.8%) patients (Group‐2). All adenosine‐provoked dormant conductions were successfully eliminated by additional ablation applications. By 12 months after the initial procedure, 72 (66.1%) patients were free of AF recurrences without any antiarrhythmic drugs. A Cox regression multivariate analysis of the variables including the adenosine‐provoked reconductions, age, gender, duration of AF, presence of hypertension or structural heart disease, left atrial size, left ventricular ejection fraction, and body mass index demonstrated that adenosine‐provoked reconductions were an independent predictor of AF recurrence after a single ablation procedure (hazard ratio: 1.387; 95% confidence interval: 1.018–1.889, P = 0.038). At the repeat session for recurrent AF, conduction recovery was observed similarly in both groups (P = 0.27). Conclusion: Even after the elimination of any adenosine‐provoked dormant PV conduction, the appearance of acute adenosine‐provoked reconduction after the PVAI was an independent predictor of AF recurrence after a single AF ablation procedure. (J Cardiovasc Electrophysiol, Vol. 23 p. 256‐260, March 2012.)     

Carto指引下环肺静脉导管消融术的达终点靶点分析及临床评价

目的:探讨环肺静脉导管消融术(CPVI)达终点部位及其分布规律,更有效地指导其达到肺静脉电隔离。方法:96例药物治疗无效的有临床症状的心房颤动患者。通过Carto电解剖标测系统三维标测指引下行CPVI。消融终点为完成环状消融线并实现肺静脉电位消失即肺静脉电隔离。结果:96例患者CPVI时记录到的消融靶点达终点部位203处,包括左侧肺静脉114处,位于左前上(45处,39.5%),左前下(26处,22.8%)和左前中(16处,14.0%);环右侧肺静脉89处,分别位于右后上(40处,44.9%)和右中下(27处,30.3%)。9例再次行CPVI的电隔离者与上述部位一致。手术并发症包括:1例少量心包积液,1例顽固性呃逆,血气胸1例,迷走反射2例,2例颈部血肿。结论:CPVI达终点部位有一定规律,多见于左侧肺静脉消融线前壁和右侧肺静脉消融线后壁,可为再次消融有效提示消融达终点部位的大体位置。     

Prevalence of asymptomatic recurrences of atrial fibrillation after successful radiofrequency catheter ablation

INTRODUCTION: The long-term efficacy of radiofrequency catheter ablation of atrial fibrillation (AF) has been based on patient-reported symptoms suggestive of AF. However, asymptomatic recurrences of AF may remain undetected. The aim of this study was to determine the prevalence of asymptomatic recurrences of AF after an apparently successful catheter ablation procedure for AF. METHODS AND RESULTS: Among 244 consecutive patients (mean age 53 +/- 11 years) who underwent a pulmonary vein isolation procedure for symptomatic paroxysmal AF and who reported no symptoms of recurrent AF at > or =6 months after the procedure, 60 patients with a history of > or =1 episode of AF per week were asked to participate in this study. Preablation, these patients had experienced 19 +/- 13 episodes of AF per month. The patients were provided with a patient-activated transtelephonic event recorder for 30 days, a mean of 642 +/- 195 days after the ablation procedure, and were asked to record and transmit recordings on a daily basis and whenever they felt palpitations. Seven patients (12%) felt palpitations during the study, although they had not experienced symptoms previously. Each of these 7 patients had an episode of AF documented with the event monitor during symptoms. In these 7 patients, the mean number of episodes per month decreased from 19 +/- 14 preablation to 3 +/- 1 postablation (P < 0.001). Among the 53 asymptomatic patients, an episode of AF was captured in 1 (2%) patient during the study period. CONCLUSION: Asymptomatic recurrences of AF after an apparently successful catheter ablation procedure for symptomatic paroxysmal AF are infrequent.     

Our approach to management of patients with pulmonary vein stenosis following AF ablation

Despite advances in the approach to pulmonary vein isolation, pulmonary vein stenosis remains an important morbid complication affecting approximately 1.3% of procedures. Patients with symptomatic pulmonary vein stenosis are typically referred for intervention with either balloon angioplasty or stenting. A significant portion of patients with severe pulmonary vein stenosis are asymptomatic and are identified only if routine screening is preformed following ablation. Based on available evidence, CT scanning 3 months postablation appears to be an effective and reliable screening tool that can be used to identify asymptomatic patients with significant stenosis. The best clinical management for asymptomatic patients with severe stenosis is poorly defined. We typically refer these patients for pulmonary vein intervention; however, the patient's age, comorbidities, functional capacity, as well as the size of the pulmonary vein affected, all need to be carefully considered with the patient before proceeding.     

Pulmonary vein isolation for atrial fibrillation in patients with symptomatic sinus bradycardia or pauses

Introduction: Sick sinus syndrome is commonly associated with tachyarrhythmias and bradyarrhythmias that often are symptomatic. The aim of this study was to assess the effect of pulmonary vein isolation in patients with sick sinus syndrome and atrial fibrillation (AF).
Methods and Results: Three hundred fourteen consecutive patients who underwent pulmonary vein isolation between December 2000 and January 2002 were included in the study. Thirty-one patients had sick sinus syndrome, which was defined as a preprocedural history of symptomatic sinus bradycardia or pauses. Endpoints included AF recurrence, change in the frequency of sinus pauses, and symptoms of presyncope or syncope, as well as mean heart rate and percentage of atrial pacing in patients with pacemakers implanted prior to the pulmonary vein isolation. Patients had AF for an average of 6 ± 3 years. Patients were 58 ±8 years old and had ejection fractions of 55 ± 4%. Sixty-one percent had implanted pacemakers. AF recurred within 6 months in 4 patients. Two had a successful second pulmonary vein isolation procedure. There were no recurrences of presyncopal events (P < 0.05) or documented sinus pauses (P < 0.05) after successful pulmonary vein isolation in the patients without permanent pacemakers. Patients with pacemakers had a 13-fold reduction in the percentage of atrial pacing (P < 0.05). Both groups showed a significant increase in average heart rates at 6-month follow-up.
Conclusion: Cure of AF by pulmonary vein isolation helped resolve the clinical manifestations of sick sinus syndrome, suggesting that the occurrence of AF and/or the associated treatment could be partially responsible for sick sinus syndrome. (J Cardiovasc Electrophysiol, Vol. 15, pp. 784-789, July 2004)     

A novel mesh electrode catheter for mapping and radiofrequency delivery at the left atrium-pulmonary vein junction: a single-catheter approach to pulmonary vein antrum isolation

Background: Electrical isolation of pulmonary veins (PV) by radiofrequency (RF) ablation is often performed in patients with atrial fibrillation (AF). Current catheter technology usually requires the use of a multielectrode catheter for mapping in addition to the ablation catheter.
Purpose: We evaluated the feasibility and safety of using a single, expandable electrode catheter (MESH) to map and to electrically isolate the PV.
Methods and Results: Nineteen closed-chest mongrel dogs, weighing 23–35 kg, were studied under general anesthesia. Intracardiac echocardiography (ICE) was used to guide transseptal puncture and to assess PV dimensions and contact of the MESH with PV ostia. ICE and angiography of RSPV were obtained before and after ablation, and prior to sacrifice at 7–99 days. An 11.5 Fr steerable MESH was advanced and deployed at the ostium of the RSPV. Recordings were obtained via the 36 electrodes comprising the MESH. For circumferential ablation, RF current was delivered at a target temperature of 62–65°C (4 thermocouples) and maximum power of 70–100 W for 180 to 300 seconds. Each animal received 1–4 RF applications. Entrance conduction block was obtained in 13/19 treated RSPVs. Pathological examination confirmed circumferential and transmural lesions in 13 of 19 RSPV. LA mural thrombus was present in 3 animals. There was no significant PV stenosis.
Conclusion: Based on this canine model, a new expandable MESH catheter may safely be used for mapping and for PV antrum isolation. This approach may decrease procedure time without compromising success rate in patients undergoing AF ablation.     

心房颤动肺静脉电隔离术后早期复发的临床意义

目的:总结分析心房颤动(房颤)肺静脉电隔离术后早期(2周内)房颤复发者的随访结果.方法:105例房颤患者[平均年龄(55±12)岁],采用导管进行环肺静脉电隔离治疗,其中阵发性房颤78例,持续性房颤27例.实施环肺静脉电隔离共358根.结果:在术后早期随访[平均(3.9±2.6)d]中,105例患者中38例(36%)复发房颤.阵发性房颤与持续性房颤者早期房颤复发的发生率相比,差异无统计学意义(35%∶41%,P>0.05).在后期随访[平均(208±125)d]中,67例早期未复发患者中58例(87%)、38例早期房颤复发患者中13例(34%)无房颤发生,二者成功率比较,P<0.01.结论:肺静脉电隔离术后2周内大约36%患者房颤复发,早期房颤复发患者较早期未复发者后期成功率低.     

Tachycardia and bradycardia coexisting in the same pulmonary vein

During segmental isolation of the pulmonary veins (PVs) in a patient with paroxysmal atrial fibrillation, there was a PV bradycardia that was dissociated from the left atrium in a segment of the right superior PV, whereas the remaining segments showed passive activation of a PV fascicle during sinus rhythm. Rapid atrial pacing induced a PV tachycardia in the nonisolated fascicles, and the dissociated PV bradycardia persisted in a segment of the same PV. These observations indicate that PV fascicles are insulated from each other and that a dissociated PV rhythm does not necessarily indicate complete isolation of a PV.     

Comparison of stent versus balloon angioplasty for pulmonary vein stenosis complicating pulmonary vein isolation

Introduction: Pulmonary vein stenosis (PVS) is a rare but significant complication of pulmonary vein isolation (PVI). Dilation and stent angioplasty have been described but not compared.
Methods and Results: All percutaneous interventions for PVS complicating PVI between December 2000 and March 2007 were reviewed. Acute success, defined as post-intervention stenosis ≤30%, and long-term outcome of dilation versus stent angioplasty were compared. Freedom from restenosis was defined as freedom from repeat intervention. Overall outcome for all interventions was examined. We studied 34 patients with 55 stenotic veins followed for a mean of 25 months. Dilation was performed in 39 veins and stenting in 40 veins (16 primarily, 24 after dilation restenosis). Acute success and restenosis rates were 42% and 72% for dilation versus 95% (P < 0.001) and 33% for stenting. Time to restenosis was greater for stent angioplasty (P = 0.003). Stents ≥10 mm in diameter had lower restenosis than smaller stents. Risk factors for restenosis included small reference vessel diameter and longer time from PVI to intervention for PVS. All but two patients experienced improvement (n = 10) or resolution of symptoms (n = 22). The mean percent stenosis decreased from 82% to 21% for the entire cohort and mean flow to the lung quadrant increased from 10% to 17%.
Conclusion: Stent angioplasty results in less restenosis than dilation, particularly for stents ≥10 mm. Early referral may improve long-term patency by minimizing reference vessel atrophy. Most patients with PVS post-PVI can be improved symptomatically with catheter intervention.     

Left atrial stiffness relates to left ventricular diastolic dysfunction and recurrence after pulmonary vein isolation for atrial fibrillation

Left Atrial Stiffness and Atrial Fibrillation . Introduction: An increased left atrial (LA) stiffness reflects the structural remodeling and deterioration of the LA function. This study was designed to estimate LA stiffness by measuring a combination of the strain and LA pressure in patients undergoing pulmonary vein isolation (PVI) of atrial fibrillation (AF) and to evaluate the influence of the LA stiffness on the cardiac function, serum markers, and recurrence of AF after PVI. Methods: In 155 consecutive patients with AF, the brain natriuretic peptide (BNP) and aminoterminal procollagen type III propeptide (PIIIP) plasma levels were measured before the PVI. The difference between the minimum and maximum LA systolic pressures was directly measured by a transseptal puncture. The ratio of the difference in the LA pressures to the peak systolic LA strain evaluated by speckle‐tracking echocardiography was used as an index of the LA stiffness. Results: The calculated LA stiffness index was related to the BNP level (r_s= 0.444, P < 0.001), E/E′ ratio (r_s= 0.444, P < 0.001), LA volume index (r_s= 0.370, P < 0.001), and PIIIP level (r_s= 0.305, P = 0.002). During a mean follow‐up period of 33.8 ± 12.2 months, 45 patients (29%) presented with AF recurrences. A Cox proportional hazard regression analysis showed the LA stiffness index was an independent predictor of recurrence of AF (HR 2.88; 95% CI 1.75 to 4.73, P < 0.001). Conclusions: In patients with AF, the LA stiffness index is related to left ventricular diastolic dysfunction, LA dilatation, and collagen synthesis and may predict AF recurrences after PVI. (J Cardiovasc Electrophysiol, Vol. 22, pp. 999‐1006, September 2011)     

Incidence and time course of early recovery of pulmonary vein conduction after catheter ablation of atrial fibrillation

Background: Although it is well recognized that recovery of pulmonary vein (PV) conduction is common among patients who fail atrial fibrillation (AF) ablation, little is known about the precise time course of recurrence.
Objective: To determine the incidence and time course of early recurrence of conduction after PV isolation during AF ablation.
Methods: The patient population was composed of 14 consecutive patients (9 men [64%]; age 56 ± 7 years) with AF who underwent radiofrequency catheter ablation via circumferential ablation with PV isolation, determined by a circular mapping catheter. After successful isolation of the PVs, repeat circular electrode recordings from each PV were obtained at 30 and 60 minutes.
Results: After complete isolation of all PVs, early PV recurrence was observed in 13 (93%) patients and 26 veins (50%). Seventeen veins (33%) showed a first recurrence at 30 minutes, while nine veins (17%) showed a first recurrence at 60 minutes.
Conclusion: The results reveal an extremely high rate of early recurrence of PV conduction following AF ablation. It is particularly notable that about one-fifth of the veins remained isolated at 30 minutes, but subsequently developed recurrence between 30 and 60 minutes. Of the veins that showed early recurrence, one-third developed a first recurrence at 60 minutes. These findings suggest that AF ablation procedures should incorporate a 60-minute waiting period after initial isolation in order to detect early recurrence of conduction.     

Pulmonary vein conduction is the major finding in patients with atrial tachyarrhythmias after intraoperative maze ablation

Introduction: Electrophysiological (EP) data from patients with recurrent atrial tachyarrhythmias (ATa) after intraoperative maze ablation are limited. Furthermore, the clinical course after accomplishing pulmonary vein (PV) isolation using the double lasso technique (DLT) is unknown.
Methods and Results: EP study and catheter ablation (CA) was guided by a three-dimensional electroanatomic mapping system (3-D EA, CARTO, Biosense-Webster) combined with simultaneous ipsilateral PV mapping using the DLT. Defined endpoints were: (1) identification of conduction gaps within the ipsilateral PVs, (2) elimination of all PV spikes, and (3) ablation of clinical ATas.
CA was performed in eight patients (four females, 62 ± 5 years, LA: 50 ± 6 mm) with drug refractory ATa (9.1 ± 6.3 years) despite non-"cut and sew" maze operation. Electrical PV conduction was demonstrated in the majority of patients (7/8). All endpoints were achieved. Repeat ablations were required in three patients. Second ablation was due to typical atrial flutter (n = 1) and atrial fibrillation (n = 2). One patient required three ablations due to a left atrial macroreentrant tachycardia. During a mean follow-up of 15.5 ± 4.8 months, 7/8 patients were free of ATa recurrences.
Conclusion: Incomplete lesions after non-"cut and sew" maze operation are associated with PV conduction and recurrence of ATas. Electrical isolation of ipsilateral PVs and completion of linear lesions guided by 3-D EA mapping is feasible and successful in maintaining sinus rhythm during mid term follow-up. Completeness of linear lesions using EP endpoints should be confirmed during the initial surgical procedure to minimize ATa recurrences.     

Clinical predictors of arrhythmia recurrences following pulmonary vein antrum isolation for atrial fibrillation: predicting arrhythmia recurrence post-PVAI

Predicting Arrhythmia Recurrence Post‐PVAI . Introduction: Pulmonary vein antrum isolation (PVAI) is an accepted treatment for atrial fibrillation (AF) refractory to medical therapy. The purpose of this study was to identify the patient, procedural, and follow‐up factors associated with arrhythmia recurrences following PVAI. Methods and Results: Clinical data were prospectively collected on all 385 consecutive patients who had 530 PVAI (age 58 ± 11 years, 63% paroxysmal AF–PAF, follow‐up 2.8 ± 1.2 years) between February 2004 and March 2009. ECGs were recorded at each follow‐up visit with Holter monitoring 1, 3, 6, and 12 months following PVAI and every 6 months thereafter. Recurrences < 3 months post‐PVAI were defined as early, 3 months—1 year post‐PVAI as late, and > 1 year post‐PVAI as very late. Relationship between predictor variables and outcomes was modeled using Cox proportional hazards analysis. Late recurrences occurred in 42% with a lower rate among PAF versus non‐PAF patients (39% vs 56%, P = 0.001). Of the 256 patients with ≥ 1‐year follow‐up, 121 (47%) had no arrhythmia off antiarrhythmic drugs (AADs) 1 year post‐PVAI; 36 (30%) of these had a very late recurrence. In multivariate analysis, non‐PAF, hypertension, and prior AAD failure predicted recurrence. When entered into the model, early recurrences remained the only predictor of late recurrences. Conclusion: Patients with non‐PAF, hypertension, and prior failure of multiple AAD were more likely to experience arrhythmia recurrence post‐PVAI. Early recurrences were the strongest predictor of late recurrences. Late and very late recurrences following PVAI were common and should be considered when planning long‐term AF patient management. (J Cardiovasc Electrophysiol, Vol. pp. 1‐9)     

Left atrial flutter following pulmonary vein antrum isolation with radiofrequency energy: linear lesions or repeat isolation

INTRODUCTION: Left atrial flutter (LAFL) is a known complication of pulmonary vein isolation. Treatment of this arrhythmia currently involves both linear lesions as well as re-isolation. However, it is unknown if re-isolation alone is sufficient to prevent recurrence. This study reviews the incidence of LAFL following segmental PV antrum isolation (PVAI) in a large patient population and evaluates if re-isolation alone is sufficient to prevent recurrence. METHODS AND RESULTS: Seven hundred thirty-seven patients underwent PVAI. Twenty-three patients (3.1%) developed post-PVAI LAFL. All patients underwent a second procedure in which only repeat PVAI was done. During the second procedure, all flutter circuits were electroanatomically mapped. All patients were followed at 3, 6, and 12 months. All 23 patients demonstrated recovery in one or more PV. After repeat isolation of the PVs, 61% of patients were arrhythmia free off all antiarrhythmic drugs. A relationship between the presence/absence of pre-existing left atrial (LA) scar was observed. Of the 11 patients with pre-existing LA scar, 36% remained arrhythmia free off antiarrhythmic drugs. In contrast, of the 12 patients without pre-existing LA scar, 83% remained arrhythmia free off antiarrhythmic drugs (P = 0.03). CONCLUSION: Among patients with LAFL following PVAI, re-isolation alone is sufficient in preventing recurrence in patients without pre-existing LA scar. Patients with pre-existing LA scar tend to have recurrence requiring further ablation including linear lesions, and continue to need antiarrhythmic medications.