Importance of non–pulmonary vein triggers ablation to achieve long-term freedom from paroxysmal atrial fibrillation in patients with low ejection fraction

Impact of Alcohol Consumption on the Outcome of Catheter Ablation in Patients With Paroxysmal Atrial Fibrillation

BACKGROUND

Although several studies have reported an association between atrial fibrillation (AF) and alcohol, the impact of alcohol consumption on the outcome after catheter ablation (CA) for AF has not been discussed. We aimed to elucidate the effect of alcohol consumption on the outcome of CA for paroxysmal AF.

METHODS AND RESULTS

We examined 1361 consecutive patients with paroxysmal AF (mean age, 61±11 years, 334 women) who underwent CA, including 623 (45.8%) patients who consumed alcohol. The clinical characteristics and outcomes of CA were compared between patients who did and did not consume alcohol. No significant differences were seen in the left atrial size, duration of AF history, and incidence of nonpulmonary vein foci between 2 groups (P=NS). Although the AF recurrence-free rate after the initial CA was higher in patients who did not consume alcohol (261/623 [41.9%] versus 252/738 [34.1%]; mean follow-up, 44.4±30.7 months; P=0.003), the outcome after the final CA was similar between 2 groups (patients who consumed alcohol: 111/628 [17.7%] versus patients who did not consume alcohol: 138/738 [18.7%]; mean follow-up, 53.1±25.8 months; P=0.67). The frequency (hazard ratio 1.07 per 1 day/week increase, CI 1.00-1.15, P=0.04) of alcohol consumption was significantly associated with AF recurrence after CA.

CONCLUSIONS

The frequency of alcohol consumption may be associated with AF recurrence after the initial CA for paroxysmal AF, but it may not affect the outcome after the final CA.

Impact of Catheter Ablation for Paroxysmal Atrial Fibrillation in Patients With Sick Sinus Syndrome - Important Role of Non-Pulmonary Vein Foci

BACKGROUND

The clinical efficacy of catheter ablation (CA) for paroxysmal atrial fibrillation (PAF) in patients with sick sinus syndrome (SSS) and the mechanism and predictors of recurrence are not yet completely elucidated.

METHODS AND RESULTS

Of 963 consecutive patients who underwent PAF ablation during the study period, a total of 108 patients with SSS (SSS group) and 108 matched controls without SSS (non-SSS group) were followed up. During the follow-up period (mean, 32.8±17.5 months), the SSS group had significantly higher AF recurrence rate since the last procedure than the non-SSS group (26.9% vs. 12.0%; P=0.02). The SSS group had significantly higher prevalence of non-pulmonary vein (non-PV) foci than the non-SSS group (25.9% vs. 13.9%; P=0.027). On multivariate analysis congestive heart failure (HR, 13.7; 95% CI: 1.57-119; P=0.02) and non-PV foci (HR, 5.75; 95% CI: 1.69-19.6; P=0.005) were independent predictors of recurrence following CA in the SSS group. In the SSS group, 88 patients had bradycardia-tachycardia syndrome without prior permanent pacemaker implantation. Of these, 6 required pacemaker implantation because of AF and sinus pause recurrence.

CONCLUSIONS

Patients with SSS are at higher risk of AF recurrence after CA. Non-PV foci are associated with AF recurrence following PAF with SSS.

Pharmacological Tests in Atrial Fibrillation Ablation

The invasive management of atrial fibrillation (AF) has been considerably changed by the identification of major sites of AF initiation and/or maintenance within the pulmonary vein antra. Percutaneous catheter ablation of these targets has become the standard of care for sustained maintenance of sinus rhythm. Long-term failure of ablation is related to an inability to create a durable transmural lesion or to identify all of the non-pulmonary vein arrhythmia triggers. Pharmacological challenges during catheter ablation have been suggested to improve outcomes in both paroxysmal and persistent AF. Herein we review the mechanism and evidence for the use of pharmacological adjuncts during the catheter ablation of AF.

Prevalence and distribution of focal triggers in persistent and long-standing persistent atrial fibrillation

BACKGROUND

The relevance of focal triggers in persistent atrial fibrillation (PerAF) and long-standing persistent atrial fibrillation (LSPAF) has not been previously investigated.

OBJECTIVE

We prospectively evaluated the prevalence and distribution of AF triggers in patients referred for catheter ablation of PerAF and LSPAF.

METHODS

We analyzed consecutive patients undergoing first time AF ablation who underwent a standardized trigger protocol including cardioversion of induced or spontaneous AF and infusion of up to 20 μg of isoproterenol for 15-20 minutes either before or after pulmonary vein (PV) isolation accomplished. Triggers were defined as AF/sustained atrial tachyarrhythmia or repetitive atrial premature depolarizations.

RESULTS

A total of 2168 patients were included (mean age 57 ± 11 years; 1636 [75%] men), with 1531 patients having paroxysmal AF (PAF) (71%), 496 having PerAF (23%), and 141 having LSPAF (7%). PV triggers were found in 1398 patients with PAF (91%), 449 patients with PerAF (91%), and 129 patients with LSPAF (91%) (P = .856 for comparison across groups). Non-PV triggers were elicited in a total of 234 patients (11%), and the prevalence was similar across the different types of AF (PAF, 165 [11%]; PerAF, 54 [11%]; LSPAF, 15 [11%]; P = .996 for comparison across groups).

CONCLUSION

PVs are the main AF trigger site in patients with PerAF and LSPAF, with an overall prevalence similar to that found in patients with PAF. These results support the current recommendations for PV isolation as the cornerstone of catheter ablation to eliminate AF triggers in PerAF and LSPAF.