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ablation for atrial fibrillation; pulmonary vein isolation/ablation

Indications: - pulmonary vein isolation in connection with radiofrequency catheter ablation for atrial fibrillation - persistent atrial fibrillation more difficult to ablate than paroxysmal atrial fibrillation [14] - may be treatment of choice for persistent or paroxysmal atrial fibrillation* * clinically significant improvements in quality of life at 12 months [12,13] * improvement in quality of life associated with reduced atrial fibrillation burden [17] * clinically signitifant decrease in atrial fibrillation burden at 6 months with improvements in quality of life [24] * compared with medical therapy no benefit in composite end point of death, disabling stroke, serious bleeding, or cardiac arrest [12] * 38% lower risk of atrial arrhythmias & 68% reduction in hospitalizations compared with antiarrhythmic therapy for paroxysmal atrial fibrillation [20] * ablation in patients with heart failure with preserved ejection fraction experienced lower mortality & improved quality of life vs drug therapy [18] * ablations in both women & men associated with few complications & improved symptoms [19] * catheter ablation for persistent or paroxysmal atrial fibrillation - reduces dementia & mortality vs rate control with anticoagulation in older patients (>= 65 years) with or without - left ventricular systolic dysfunction - left ventricular diastolic dysfunction - hypertension - diabetes mellitus - ischemic stroke - chronic kidney disease [22] - reduces hospitalization for worsening heart failure in patients with HFrEF [23] Contraindications: - restrictive cardiomyopathy (cardiac transplantation favored) [9] Pathology: - almost all atrial fibrillation signals come from the four pulmonary veins Procedure: - insertion of an arterial catheter generally through the femoral artery into the left atrium presumably under fluoroscopy - radiofrequency energy is delivered through the catheter to the area of the left atrium that connects to the pulmonary vein (ostia) - pulsed field ablation using an energy source that selectively ablates myocardial tissue may create durable lesions [15] - balloon cryoablation equivalent to radiofrequency ablation [11] - ablation produces a circular scar that blocks any impulses firing from within the pulmonary vein, thus 'disconnecting' the aberrant conduction & preventing atrial fibrillation - addition of alcohol ablation of the vein of Marshall to pulmonary vein isolation 84% successful [16] - pulmonary vein isolation of no value in conjunction with catheter ablation for persistent atrial fibrillation [21] Complications: - cardiac tamponade - embolic stroke - atrioesophageal fistula [8] - pulmonary vein stenosis [9,10] - repeat ablations common 20-30% [8] - urosepsis (5%) [13] Notes: - compare with left atrial appendage closure (Watchman)

Related

left atrial appendage closure (Watchman device, Lariat device) pulmonary vein

General

radiofrequency catheter ablation

References

  1. Cleveland Clinic Pulmonary vein ablation http://my.clevelandclinic.org/heart/atrial_fibrillation/pulmonaryvein_ablation.aspx
  2. Wazni OM, Marrouche NF, Martin DO, Verma A, Bhargava M, Saliba W, Bash D, Schweikert R, Brachmann J, Gunther J, Gutleben K, Pisano E, Potenza D, Fanelli R, Raviele A, Themistoclakis S, Rossillo A, Bonso A, Natale A. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA. 2005 Jun 1;293(21):2634-40. PMID: 15928285
  3. Oral H et al, Circumferential pulmonary vein ablation for chronic atrial fibrillation. N Engl J Med 2006; 354:934 PMID: 16510747 - Wood MA and Ellengboogen KA, Catheter ablation of chronic atrial fibrillation - The gap between promise and pactice N Eng J Med 2006; 354:934 PMID: 16510752
  4. Fuster V et al, ACC.AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation - Executive Summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). J Am Coll Cardiol 2006, 48:854 PMID: 16904574
  5. Pappone C et al, A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation. The APAF study. J Am Coll Cardiol 2006, 48:2340 PMID: 17161267
  6. Khan MN et al. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med 2008 Oct 23; 359:1778. PMID: 18946063
  7. Journal Watch 23(17):135, 2003 - Pappone C et al Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study. J Am Coll Cardiol 42:185, 2003 PMID: 12875749 - Ellenbogen KA & Wood MA Ablation of atrial fibrillation: awaiting the new paradigm. J Am Coll Cardiol 42:198, 2003 PMID: 12875750
  8. Verma A et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med 2015 May 7; 372:1812 PMID: 25946280
  9. Medical Knowledge Self Assessment Program (MKSAP) 17, 19. American College of Physicians, Philadelphia 2015, 2022
  10. Holmes DR Jr, Monahan KH, Packer D Pulmonary vein stenosis complicating ablation for atrial fibrillation: clinical spectrum and interventional considerations. JACC Cardiovasc Interv. 2009 Apr;2(4):267-76 PMID: 19463436
  11. Kuck KH et al. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med 2016 Apr 4 PMID: 27042964 http://www.nejm.org/doi/10.1056/NEJMoa1602014
  12. Mark DB, Anstrom KJ, Sheng S et al Effect of Catheter Ablation vs Medical Therapy on Quality of Life Among Patients With Atrial Fibrillation. The CABANA Randomized Clinical Trial. JAMA. Published online March 15, 2019 PMID: 30874716 https://jamanetwork.com/journals/jama/fullarticle/2728675 - Packer DL, Mark DB, Robb RA et al Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation. The CABANA Randomized Clinical Trial. JAMA. Published online March 15, 2019 PMID: 30874766 https://jamanetwork.com/journals/jama/fullarticle/2728676 - Albert CM, Bhatt DL Catheter Ablation for Atrial Fibrillation. Lessons Learned From CABANA. JAMA. Published online March 15, 2019 PMID: 30874732 https://jamanetwork.com/journals/jama/fullarticle/2728674
  13. Blomstrom-Lundqvist C, Gizurarson S, Schwieler J et al. Effect of catheter ablation vs antiarrhythmic medication on quality of life in patients with atrial fibrillation: The CAPTAF randomized clinical trial. JAMA 2019 Mar 19; 321:1059-1068. PMID: 30874754 https://jamanetwork.com/journals/jama/fullarticle/2728485
  14. Mansour M, Calkins H, Osorio J et al. Persistent atrial fibrillation ablation with contact force sensing catheter: The prospective multicenter PRECEPT Trial. JACC Clin Electrophysiol 2020 Aug;6(8):958-969 PMID: 32819531 - Gerstenfeld EP, Moss JD. Persistent atrial fibrillation ablation: Strengthening the evidence. JACC Clin Electrophysiol 2020 Aug;6(8):970-972 PMID: 32819532 - Hussein AA, Barakat AF, Saliba WI et al Persistent Atrial Fibrillation Ablation With or Without Contact Force Sensing. J Cardiovasc Electrophysiol. 2017 May;28(5):483-488. PMID: 28185351
  15. Reddy VY et al. Pulsed field ablation in patients with persistent atrial fibrillation. J Am Coll Cardiol 2020 Sep 1; 76:1068. PMID: 32854842 https://www.sciencedirect.com/science/article/pii/S0735109720359398 - Tomlinson DR, Mandrola J. Pulsed field ablation for persistent atrial fibrillation (PersAFOne); Hope or hype? J Am Coll Cardiol 2020 Sep 1; 76:1081 PMID: 32854843 https://www.sciencedirect.com/science/article/abs/pii/S0735109720360319
  16. Link MD Alcohol Ablation of Vein of Marshall Proves Beneficial in Atrial Fibrillation. NEJM Journal Watch. Oct 27, 2020 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Valderrabano M et al. Effect of catheter ablation with vein of Marshall ethanol infusion vs catheter ablation alone on persistent atrial fibrillation: The VENUS randomized clinical trial. JAMA 2020 Oct 27; 324:1620. PMID: 33107945 https://jamanetwork.com/journals/jama/article-abstract/2772281
  17. Terricabras M, Mantovan R, Jiang CY et al. Association between quality of life and procedural outcome after catheter ablation for atrial fibrillation. JAMA Netw Open 2020 Dec 4; 3:e2025473 PMID: 33275151 PMCID: PMC7718606 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2773536
  18. Packer DL, Piccini JP, Monahan KH et al. Ablation versus drug therapy for atrial fibrillation in heart failure: Results from the CABANA trial. Circulation 2021 Feb 8; [e-pub]. PMID: 33554614
  19. Russo AM, Zeitler EP, Giczewska A et al. Association between sex and treatment outcomes of atrial fibrillation ablation versus drug therapy: Results from the CABANA trial. Circulation 2021 Feb 16; 143:661 PMID: 33499668 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.051558
  20. Turagam MK, Musikantow D, Whang W et al Assessment of Catheter Ablation or Antiarrhythmic Drugs for First-line Therapy of Atrial FibrillationA Meta-analysis of Randomized Clinical Trials. JAMA Cardiol. 2021;6(6):697-705 PMID: 33909022 PMCID: PMC8082432 (available on 2022-04-28) https://jamanetwork.com/journals/jamacardiology/fullarticle/2779384
  21. Lou N Persistent Afib: More Extensive Catheter Ablation Fails to Reduce Episodes. Pulmonary vein isolation add-on is a flop in randomized trial, MedPage Today January 10, 2023 https://www.medpagetoday.com/cardiology/arrhythmias/102576 - Kistler PM, Chieng D, Sugumar H et al Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation. The CAPLA Randomized Clinical Trial. JAMA. 2023;329(2):127-135. PMID: 36625809 https://jamanetwork.com/journals/jama/article-abstract/2800186
  22. Harrison SL, Buckley BJR, Austin P, Lane DA, Lip GYH. Catheter ablation and lower risk of incident dementia and mortality in older adults with atrial fibrillation. J Am Geriatr Soc. 2023. Nov. 71(11):3357-3366 PMID: 37609682 https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.18538
  23. Marrouche NF, Brachmann J, Andresen D et al Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378:417-427. Feb 1, 2018 PMID: 29385358 http://www.nejm.org/doi/full/10.1056/NEJMoa1707855 - Link MS. Paradigm Shift for Treatment of Atrial Fibrillation in Heart Failure. N Engl J Med 2018; 378:468-469. Feb 1, 2018 PMID: 29385377 http://www.nejm.org/doi/full/10.1056/NEJMe1714782
  24. Lou N Afib Ablation Delivers in First Sham-Controlled Study. More conclusive evidence for benefits on Afib burden, QoL. MedPage Today September 2, 2024 https://www.medpagetoday.com/meetingcoverage/esc/111763 - Dulai R, Sulke N, Freemantle N et al Pulmonary Vein Isolation vs Sham Intervention in Symptomatic Atrial Fibrillation. The SHAM-PVI Randomized Clinical Trial. JAMA. Published online September 2, 2024 PMID: 39221629 https://jamanetwork.com/journals/jama/fullarticle/2823283