Atrial fibrillation ablation

Radiofrequency Ablatlion and Cryotherapy in Atrial Fibrillation 109 Mapping Systems and Imaging for Atrial Fibrillation Ablation 110 Outcomes of Atrial Fibrillation Ablation 111... 

MAPPING SYSTEMS AND IMAGING FOR ATRIAL FIBRILLATION ABLATION... 

Table 6.1 Randomized trials of atrial fibrillation ablation... 

Abbreviations A4, atrial fibrillation ablation versus antiarrhythmic drugs AAD, antiarrhythmic drug APAF, ablation for paroxysmal atrial fibrillation CACAF, catheter ablation for the cure of atrial fibrillation CPVA, circumferential pulmonary vein ablation PVI, pulmonary vein isolation RAAFT, radiofrequency ablation versus antiarrhythmic drugs for atrial fibrillation treatment. 

Natale A, Raviele A, Arentz T, et al. Venice Chart international consensus document on atrial fibrillation ablation. J Cardiovasc Electrophysiol 2007 18 560-80. 

Gerstenfeld EP, Marchlinski FE. Mapping and ablation of left atrial tachycardias occurring after atrial fibrillation ablation. Heart Rhythm 2007 4 S65-72. 

Atrial tachycardia Enhanced automaticity, DAD-related automaticity, or reentry within the atrium Same as atrial fibrillation Same as atrial fibrillation Ablation of tachycardia focus ... 

Steven, D., Servatius, H., Rostock, T., Hoffmann, B., Drewitz, I., Miillerleile, K., Sultan, A., Aydin, M.A., Meinertz, T., Willems, S. Reduced fluoroscopy during atrial fibrillation ablation benefits of robotic guided navigation. J. Cardiovasc. Electrophysiol. 21(1), 6-12 (2010)... 

Reddy, V.Y., Neuzil, P., Malchano, Z.J., Vijaykumar, R., Cury, R., Abbara, S., Wei-chet, J., McPherson, C.D., Ruskin, J.N. View-synchronized robotic image-guided therapy for atrial fibrillation ablation experimental validation and clinical feasibility. Circulation 115(21), 2705-2714 (2007)... 

Fig. 4.73 The landmarks of the triangle of Koch are superimposed on the exposed right atrial cavity. The relationship of these structural landmarks to the coronary sinus is seen, (from Ho S Understanding arial anatomy Implications for atrial fibrillation ablation. In Cardiology International for a global perspective on cardiac care. London, Greycoat Publishing 2002. pp sl7-s20)...

Ho S. Understanding atrial anatomy implications for atrial fibrillation ablation. Cardiology International for a Global Perspective on Cardiac Care. Greco Publishing Ltd., S17 through S20, 2002. 

FIGURE 6-2. Algorithm for the treatment of acute (top portion) paroxysmal supraventricular tachycardia and chronic prevention of recurrences (bottom portion). Note For empiric bridge therapy prior to radiofrequency ablation procedures, calcium channel blockers (or other atrioventricular [AV] nodal blockers) should not be used if the patient has AV reentry with an accessory pathway. (AAD, antiarrhythmic drugs AF, atrial fibrillation AP, accessory pathway AVN, atrioventricular nodal AVNRT, atrioventricular nodal reentrant tachycardia AVRT, atrioventricular reentrant tachycardia DCC, direct-current cardioversion ECG, electrocardiographic monitoring EPS, electrophysiologic studies PRN, as needed VT, ventricular tachycardia.)... 

Gillinov AM, Wolf RK. Surgical ablation of atrial fibrillation. Prog Cardiovasc Dis. 2005 48 169-177. 

Anticoagulation in radiofrequency ablation of atrial fibrillation and atrial flutter... 

Haissaguerre M, et al. Mapping-guided ablation of pulmonary veins to cure atrial fibrillation. Am J Cardiol 2000 86(9 Suppl l) K9-KI9. 

Pappone C, et al. Atrial electroanatomic remodeling after circumferential radiofrequency pulmonary vein ablation efficacy of an anatomic approach in a large cohort of patients with atrial fibrillation, Circulation 2001 104(21) 2539—2544. 

Haissaguerre M, etal, Electrophysiological end point for catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci, Circulation 2000 101 (12) 1409— 1417. 

Pappone C, et al. Circumferential radiofrequency ablation of pulmonary vein ostia A new anatomic approach for curing atrial fibrillation. Circulation 2000 102(21 ) 261 9-2628. HohnloserSH, Kuck KH, LilienthalJ. Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF) a randomised trial. Lancet 2000 356(9244) 1789-1794. 

FIGURE 6-1. Algorithm for the treatment of atrial fibrillation (AF) and atrial flutter. °lf AF <48 hours, anticoagulation prior to cardioversion is unnecessary may consider transesophageal echocardiogram (TEE) if patient has risk factors for stroke. Ablation may be considered for patients who fail or do not tolerate one antiarrhythmic drug (AAD). Chronic antithrombotic therapy should be considered in all patients with AF and risk factors for stroke regardless of whether or not they remain in sinus rhythm. (BB, 8-blocker CCB, calcium channel blocker p.e., verapamil or diltiazem] DCC, direct-current cardioversion.)... 

Flecainide slows conduction in all cardiac cells including the anomalous pathways responsible for the Wolff-Parkinson-White (WPW) syndrome. Together with encainide and moricizine, it underwent clinical trials to establish if suppression of asymptomatic premature beats with antiarrhythmic drugs would reduce the risk of death from arrhythmia after myocardial infarction. The study was terminated after preliminary analysis of 1727 patients revealed that mortality in the groups treated with flecainide or encainide was 7.7% compared with 3.0% in controls. The most likely explanation for the result was the induction of lethal ventricular arrhythmias possibly due to ischaemia by flecainide and encainide, i.e. a proarrhythmic effect. In the light of these findings the indications for flecainide are restricted to patients with no evidence of structural heart disease. The most common indication, indeed where it is the drug of choice, is atrioventricular re-entrant tachycardia, such as AV nodal tachycardia or in the tachycardias associated with the WPW syndrome or similar conditions with anomalous pathways. This should be as a prelude to definitive treatment with radiofrequency ablation. Flecainide may also be useful in patients with paroxysmal atrial fibrillation. 

Arruodarone is used in chronic ventricular arrhythmias in atrial fibrillation it both slows the ventricular response and may restore sinus rhythm it may be used to maintain sinus rhythm after cardioversion for atrial fibrillation or flutter. Amiodarone should no longer be used for the management of reentrant supraventricular tachycardias associated with the Wolff-Parkinson-White syndrome as radiofrequency ablation is preferable. 

It is doubtful whether this differs in its origins or sequelae from atrial fibrillation. The ventricular rate is usually faster (typically, half an atrial rate of 300, where 2 1 block is present), which is too fast to leave without treatment. Since, similarly, the patient is unlikely to have been in this rhythm for a prolonged period, there is less likelihood that atrial thrombus has accumulated. Conversion without prior anticoagulation may occasionally be considered safe but anticoagulation is usually also needed. Patients should not be left in chronic atrial flutter, and DC conversion will usually restore either sinus rhythm or result in atrial fibrillation. The latter is treated as above. Patients who fail to convert, or who revert to atrial flutter should be referred for consideration of radiofrequency ablation that is highly effective and may remove the cause of the atrial flutter > 80% of cases. 

This occurs in otherwise healthy individuals, who possess an anomalous (accessory) atrioventricular pathway they often experience attacks of paroxj mal AV re-entrant tachycardia or atrial fibrillation. Drugs that both suppress the initiating ectopic beats and delay conduction through the accessory pathway are used to prevent attacks e.g. flecainide, sotalol or amiodarone. Verapamil and digoxin may increase conduction through the anomalous pathway and should not be used. Electrical conversion may be needed to restore sinus rhythm when the ventricular rate is very rapid. Radiofrequency ablation of aberrant pathways will almost certainly provide a cure. 

A 56-year-old man was given adenosine 12 mg for a narrow-complex tachycardia on four occasions, and on each occasion developed transient atrial fibrillation for a few minutes thereafter. He had a concealed left-sided accessory pathway, which was successfully ablated (23). 

Amiodarone has been reported to cause atrial flutter in 10 patients who had been given it for paroxysmal atrial fibrillation (56). In nine of those the atrial flutter was successfully treated by catheter ablation. However, during a mean follow-up period of 8 months after ablation, atrial fibrillation occurred in two patients who had continued to take amiodarone this was a lower rate of recurrence than in patients in whom atrial flutter was not associated with amiodarone. The authors therefore suggested that in patients with atrial flutter secondary to amiodarone given for atrial fibrillation, catheter ablation allows continuation of amiodarone therapy. 

Qf 136 patients with atrial fibrillation treated with either amiodarone (n = 96) or propafenone (n = 40), 15 developed subsequent persistent atrial flutter, nine of those taking amiodarone and six of those taking propafenone (58). In all cases radiofrequency ablation was effective. It is not clear to what extent these cases of atrial flutter were due to the drugs, although the frequency of atrial flutter in previous studies with propafenone has been similar. Atrial enlargement was significantly related to the occurrence of persistent atrial flutter in these patients. 

Reithmann C, Hoffmann E, Spitzlberger G, Dorwarth U, Gerth A, Remp T, Steinbeck G. Catheter ablation of atrial flutter due to amiodarone therapy for paroxysmal atrial fibrillation. Eur Heart J 2000 21(7) 565-72. 

Tai CT, Chiang CE, Lee SH, Chen YJ, Yu WC, Feng AN, Ding YA, Chang MS, Chen SA. Persistent atrial flutter in patients treated for atrial fibrillation with amiodarone and propafenone electrophysiologic characteristics, radiofrequency catheter ablation, and risk prediction. J Cardiovasc Electrophysiol 1999 10(9) 1180-7. 

---