Atrial fibrillation ablation: importance of cavotricuspid isthmus block

Rui Candeias, Pedro Adragcão, Diogo Cavaco, Katya Reis-Santos, Pinheiro Vieira, Francisco Morgado, Daniel Bonhorst, Aniceto Silva
Portuguese Journal of Cardiology: An Official Journal of the Portuguese Society of Cardiology 2009, 28 (10): 1031-40

INTRODUCTION AND OBJECTIVE: Maintenance of atrial fibrillation (AF) depends on the presence of multiple reentrant circuits in the atria. In AF ablation, after pulmonary vein (PV) isolation, substrate modification can be increased by performing linear lesions in the left atrium that reduce the fibrillatory surface. A cavotricuspid isthmus (CTI) block may be an easier and safer alternative to left atrial lines for this purpose. Non-inducibility after AF ablation is associated with a higher success rate. The aim of this study is to assess whether CTI ablation after PV isolation reduces inducibility of atrial arrhythmias, particularly AF.

METHODS AND RESULTS: In 29 consecutive patients (23 male, mean age 54.6+/-11.4 years, 11 (38%) with hypertension and four (14%) with structural heart disease, mean left atrial dimension 43+/-6 mm) undergoing PV isolation for paroxysmal or persistent AF, atrial arrhythmia inducibility was tested before and after CTI ablation. The procedure was performed using a CARTO-Merge mapping system, one or two Lasso catheters, an irrigated ablation catheter and radiofrequency energy. Atrial arrhythmia inducibility was tested with burst pacing down to 150 ms or atrial refractoriness from the proximal coronary sinus. Atrial arrhythmias were considered inducible if they persisted for more than 60 seconds. Of the 29 patients, 26 (90%) had an inducible arrhythmia before CTI ablation--AF in 16, typical atrial flutter (AFL) in seven and atypical AFL in three. Three (10%) were non-inducible. After CTI ablation, only 11 patients (38%) maintained arrhythmia inducibility (p<0.001)--AF in nine and atypical AFL in two. There was a significant reduction of AF inducibility (16 vs. 9/29, p=0.016) and of combined AF and atypical AFL inducibility (19 vs. 11/29, p=0.021). After one year of follow-up, 23 patients (79%) had no recurrence of arrhythmia. Success rates were 83% in patients without and 73% in patients with inducible arrhythmias at the end of the procedure (p=NS).

CONCLUSION: CTI ablation, in addition to PV isolation, significantly reduced the number of patients with inducible atrial arrhythmias and inducible AF.

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