Complete Pulmonary Vein Isolation for Atrial Fibrillation

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US Cardiology, 2006;3(2):1-5

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Recent studies have demonstrated that myocardium around pulmonary vein (PV) ostia plays an important role in the initiation and perpetuation of atrial fibrillation (AF).1-11 This important finding has led to the development of segmental PV ostial isolation,3-6 circumferential ablation or isolation around the PVs using circular linear lesions guided by 3D electroanatomic mapping.7-11 Substrate modification with the use of limited linear ablation has also been demonstrated to improve the clinical outcome after PV isolation in patients with AF inducibility.12-13 However, the most useful method in the majority of the ablation centers is PV isolation either using segmental PV isolation or complete PV isolation guided by 3-D mapping and Lasso catheters. In this manuscript we describe our methods of left atrial ablation and clinical outcome after the ablation in patients with paroxysmal or persistent AF.

Complete PV Isolation Using 3-D Mapping and Lasso Technique

The ablation procedure is performed under sedation with a continuous infusion of propofol. All procedures consist of the following steps:10-11

 

  • Three 8F SL1 sheaths (St Jude Medical, Inc) are advanced to the LA by a modified Brockenbrough technique: two sheaths over one puncture site and the third sheath via a second puncture site. One puncture is always performed at the infero-posterior site of the foramen ovale for easy access to the right inferior vein and the atrial myocardium. After transseptal catheterization, intravenous heparin is administered to maintain an activated clotting time of 250-300 seconds. Additionally, continuous infusions of heparinized saline are connected to the transseptal sheaths (flow rate of 10ml/h) to avoid thrombus formation or air embolism.
  • Three-dimensional mapping (CARTO or NavX) is performed with a 3.5mm-tip catheter (ThermoCool Navi-Star, Biosense-Webster, USA) or 4mm-tip catheter (Biosense-Webster, USA) during coronary sinus pacing, sinus rhythm or AF. Mapping is only performed in the left atrium, all mapping points deep within the PV have to be deleted to ensure that the posterior wall is flat in the right lateral and left lateral view (see Figure 1a and 1b).
  • After LA reconstruction, each PV ostium is identified by selective venography and carefully tagged on the electroanatomical map.We arbitrarily defined any point with clear PV-LA inflection and marked the opposite points with perpendicularity to the PV on the RAO 30 or LAO 40. This step is the most important part to achieve a successful PV isolation. In our experience, the misunderstanding of the PV ostium may sometimes make the ablation more difficult or create potential risk for PV stenosis.14-15

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References
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