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BACKGROUND Circumferential pulmonary vein ablation is still the standard approach in patients with persistent atrial fibrillation. However, the results are not very favourable and more complex ablation strategies are the subject of current controversy. Therefore, we have evaluated the effect of an additional linear lesion at the roof of the left atrium on the long-term outcome. METHODS A total of 125 patients with symptomatic persistent atrial fibrillation underwent a circumferential pulmonary vein ablation procedure in combination with an additional linear lesion at the roof of the left atrium (group A). The long-term follow-up data was compared to 125 patients with similar clinical characteristics who underwent circumferential pulmonary vein ablation without an additional linear lesion at the roof of the left atrium (group B). RESULTS The ablation procedure could be performed as planned in all 250 patients. Three years after catheter ablation, the success rate was 72.0% (no arrhythmia recurrence in 90 out of 125 patients) in group A and 63.2% in group B (no arrhythmia recurrence in 79 out of 125 patients; P = 0.04). There were no major complications. CONCLUSIONS Catheter ablation of persistent atrial fibrillation comprising a circumferential pulmonary vein ablation and an additional linear lesion at the roof of the left atrium provides more favourable long-term results than circumferential pulmonary vein ablation alone.

Remote magnetic navigation (RMN) is utilized for catheter guidance during pulmonary vein ablation (PVA). We aimed to determine whether the additional use of a circular mapping catheter (CMC) influences efficacy and outcome of RMN-guided PVA. A total of 80 consecutive subjects (65 % male, age 62 ± 9 years) underwent circumferential PVA with a 3D mapping system and an RMN-guided irrigated catheter. Procedural endpoint was complete PV isolation (PVI), total radiofrequency (RF) time >60 min, or procedure duration >5 h. PVI was defined as an entrance and/or exit block, diagnosed with a CMC within the PV ostium or by pacing via the roving RMN-guided catheter (single-catheter technique). Prolonged Holter monitoring after 3 and 6 months was used to detect atrial tachyarrhythmia (AT/AF) recurrences. Complete PVI was achieved in 56 % (45/80) of all subjects (isolated PVs per patient, 3.1 ± 1.2; RF time, 56.3 ± 17.2 min; procedure duration, 3.8 ± 0.8 h). Prospective validation of the single-catheter technique for diagnosing PVI demonstrated high concordance (94 %) with blinded CMC results. CMC use in first-time PVA was associated with similar total RF and procedure times but higher PV isolation rate. Upon multivariate analysis, CMC use, female gender, left PV, smaller PV ostium and repeat PVA predicted PVI during RMN-guided ablation. Persistent AF and mitral regurgitation at baseline and the number of non-isolated PVs predicted AT/AF recurrence during follow-up. Concomitant CMC use for first-time, RMN-guided PVA is associated with similar procedure duration but higher PV isolation rates as compared to a single-catheter approach. Since the number of isolated PVs predicts freedom from AT/AF, CMC utilization appears advisable for first-time, RMN-guided PVA.

Pulmonary vein ablation is increasingly used for patients with difficult to manage atrial fibrillation. Echocardiography plays a central role in the assessment of patients undergoing ablation therapy, not only in the pre-ablation patient selection and post-ablation assessment, but also in the peri-procedural guidance. Newer echocardiographic techniques including atrial mechanics measurements are also reviewed.

The purpose of this study was to compare the efficacy of focused ultrasound circumferential pulmonary vein ablation (CPVa) and BOX ablation (BOXa) in an acute atrial fibrillation (AF) model. Twenty mongrel dogs were divided into either CPVa or BOXa groups. CPV or BOX focused ultrasonic ablation was conducted in each group after successful establishment of the AF model. Before-and-after ablation left atrial effective refractory period (LAERP), AF inducibility, and induced AF lasting time were measured in both groups. The LAERP after AF model establishment was significantly shorter than that before establishment (102 ± 10 vs. 140 ± 10 ms, p

Catheter ablation can restore sinus rhythm in selected patients with atrial fibrillation (AF), but its preventive function for thromboembolic events (TE) is still underdetermined.We retrospectively studied 520 consecutive patients with AF who were referred for circumferential pulmonary vein ablation. The incidence of late TE was investigated, and the predictors of late TE were identified from analysis of the basic clinical variables of patients with late TE.Eight (1.5%) patients experienced late TE during 28+/-8 months follow-up. When TE occurred, most (6/8, 75%) patients were documented with recurrence episode. The recurrence of AF was more frequent in patients with late TE than patients without late TE (75.0% vs 30.5%, P=0.007). Multivariate logistic regression analysis identified that all risk factors, including all clinical variants prior ablation and the CHADS2 score, were not related to late TE but the presence of recurrence was the only predictor of late TE (odds ratio, 5.542; 95% confidence interval [1.416-45.013], P=0.019).Our study demonstrates a strong relationship between the recurrence after ablation and TE post-operation and supports the proposal that free of recurrence is an indication for discontinuation of anticoagulation after ablation.

Die korrekte Diagnosestellung bei komplexen Arrhythmien erfordert die genaue Kenntnis der Arrhythmiemechanismen und deren Anwendung auf den konkreten Fall. So konnte bei einem Patienten mit dilatativer Kardiomyopathie und unklarer „Sinustachykardie“ durch die Interpretation der Koronarvenensinus-Elektrogramme rasch die Moglichkeit einer linksatrialen Tachykardie aufgebracht werden. Bei einem Patienten mit Tachykardien, vorbestehendem Linksschenkelblock und Synkope ergab letztlich der Induktionsmechanismus der Tachykardie in der elektrophysiologischen Untersuchung wie auch die detaillierte Analyse des His-Bundel-Elektrogramms den Nachweis einer sich ungewohnlich prasentierenden AV-Knoten-Reentrytachykardie. Bei dem Patienten mit Breitkomplextachykardie und koronare Herzkrankheit war die erfolgreiche Ablationsbehandlung erst nach der Erkenntnis erfolgreich durchfuhrbar, dass der Zugriff zum Areal der langsamen Leitung nur von epikardial moglich ist. Atriale Makro-Reentrytachykardien nach Vorhofflimmerablation sind eine wachsende Herausforderung in der klinischen Rhythmologie. Eine derartige Konstellation wurde mit der Kasuistik Linksatriales perimitrales Vorhofflattern nach Pulmonalvenenablation analysiert.

The reliability of delayed cure of early recurrence of atrial fibrillation (ERAF) is still undetermined. Furthermore, the predictors of recurrence after delayed cure of ERAF are less investigated in depth.The purpose of this study was to investigate the long-term efficacy of delayed cure of ERAF after catheter ablation of AF and explore the he predictors of recurrence after delayed cure of ERAF.We prospectively studied 300 consecutive patients with atrial fibrillation (AF) who were referred for circumferential pulmonary vein ablation (CPVA). After a follow-up of 19.2 +/- 4.1months, of the 87 patients with early recurrence of AF 41 achieved delayed cure, 11 of them reoccurred AF subsequently. Univariate analysis showed that persistent AF, absence of pulmonary vein (PV) isolation and external cardioversion were related to reoccurrence after delayed cure. Logistic regression analysis identified only absence of PV isolation as a predictor of recurrent AF after delayed cure.Delayed cure after CPVA is relatively common and its efficacy at long-term follow-up is reasonably consistent. However, in patients without PV isolation, delayed cure is unstable and the risk of late recurrence is increased.

The success rate in patients with atrial fibrillation that were treated with pulmonary vein ablation is suboptimal. In retrospective review, those PVI patients that sustained normal sinus rhythm showed improvement in LV function and reverse remodeling of mitral apparatus when compared to those that had no response.