A Randomized Clinical Trial of Ablation Pulmonary Veins
A Randomized Clinical Trial of Ablation Pulmonary Veins
Introduction: Isolation of all pulmonary veins (PV) is advocated for treatment of paroxysmal atrial fibrillation (PAF). However, the superior PVs are responsible for most AF triggers, whereas the inferior PVs carry the higher risk for ablation-induced ostial stenosis. The aim of this study was to compare a superior PV isolation approach with isolation of all PVs for treatment of PAF.
Methods and Results: Fifty-two patients with PAF were randomized to either left superior pulmonary vein (LSPV) isolation followed by additional isolation of the right superior pulmonary vein (RSPV) in case of AF recurrence (group A, n = 27) or isolation of all four PVs followed by a repeat procedure in case of recurrence (group B, n = 25). At 1-year follow-up, 11 patients (41%) in group A and 8 patients (32%) in group B had AF relapse (P = 0.55). No significant differences in AF relapse were detected between groups at 3 and 12 months (log rank = 0.36, P = 0.54) and by Cox proportional hazards model analysis (P = 0.62). Nonsignificant PV stenosis was detected in two patients from group B. Total radiofrequency energy delivery and fluoroscopy and procedure times were lower in group A: 8.9 ± 1.4 minutes vs 25.6 ± 3.7 minutes (P < 0.001), 22.2 ± 6.8 minutes vs 62 ± 10.3 minutes (P < 0.001), and 131.8 ± 26.5 minutes vs 222.2 ± 32.3 minutes (P < 0.001), respectively.
Conclusion: A staged superior PVs isolation approach confers equal success rates but with reduced radiofrequency energy delivery and fluoroscopy and procedure times compared to isolation of all PVs at the initial ablation attempt.
Segmental ostial ablation of the pulmonary veins (PV) is an established therapeutic option for patients with paroxysmal atrial fibrillation (PAF) resulting in approximately 50% to 85% freedom from recurrent AF within the next 4 to 24 months. However, the procedure is technically demanding, often resulting in prolonged fluoroscopy times, and in up to 50% of the cases a repeat ablation is undertaken. In clinical practice not all PVs are easily isolated. Isolation of the right inferior pulmonary vein (RIPV), in particular, is technically difficult, and this vein is frequently ignored in total PV ablation procedures. Postablation PV ostial stenosis has been reported in 2% to 40% of cases, and the left inferior pulmonary vein (LIPV) is at higher risk. The prevalence of arrhythmogenic foci is higher in the superior PVs compared to the inferior PVs, and the left superior pulmonary vein (LSPV) is the vein with the longest muscular sleeve. Therefore, ablation strategies targeting the superior PVs appear as attractive options in this clinical setting.
We hypothesized that in patients with PAF, isolation of the LSPV only at the initial ablation attempt, followed by isolation of the right superior pulmonary vein (RSPV) in cases of AF recurrence instead of targeting of all veins, might simplify the ablation approach without significant reduction in the success rate of the procedure. Therefore, we conducted a prospective randomized trial of single LSPV isolation followed by additional RSPV isolation in case of AF recurrence compared to ablation of all four PVs for treatment of patients with PAF. To our knowledge, this is the first time such a randomized comparison has been conducted.
Introduction: Isolation of all pulmonary veins (PV) is advocated for treatment of paroxysmal atrial fibrillation (PAF). However, the superior PVs are responsible for most AF triggers, whereas the inferior PVs carry the higher risk for ablation-induced ostial stenosis. The aim of this study was to compare a superior PV isolation approach with isolation of all PVs for treatment of PAF.
Methods and Results: Fifty-two patients with PAF were randomized to either left superior pulmonary vein (LSPV) isolation followed by additional isolation of the right superior pulmonary vein (RSPV) in case of AF recurrence (group A, n = 27) or isolation of all four PVs followed by a repeat procedure in case of recurrence (group B, n = 25). At 1-year follow-up, 11 patients (41%) in group A and 8 patients (32%) in group B had AF relapse (P = 0.55). No significant differences in AF relapse were detected between groups at 3 and 12 months (log rank = 0.36, P = 0.54) and by Cox proportional hazards model analysis (P = 0.62). Nonsignificant PV stenosis was detected in two patients from group B. Total radiofrequency energy delivery and fluoroscopy and procedure times were lower in group A: 8.9 ± 1.4 minutes vs 25.6 ± 3.7 minutes (P < 0.001), 22.2 ± 6.8 minutes vs 62 ± 10.3 minutes (P < 0.001), and 131.8 ± 26.5 minutes vs 222.2 ± 32.3 minutes (P < 0.001), respectively.
Conclusion: A staged superior PVs isolation approach confers equal success rates but with reduced radiofrequency energy delivery and fluoroscopy and procedure times compared to isolation of all PVs at the initial ablation attempt.
Segmental ostial ablation of the pulmonary veins (PV) is an established therapeutic option for patients with paroxysmal atrial fibrillation (PAF) resulting in approximately 50% to 85% freedom from recurrent AF within the next 4 to 24 months. However, the procedure is technically demanding, often resulting in prolonged fluoroscopy times, and in up to 50% of the cases a repeat ablation is undertaken. In clinical practice not all PVs are easily isolated. Isolation of the right inferior pulmonary vein (RIPV), in particular, is technically difficult, and this vein is frequently ignored in total PV ablation procedures. Postablation PV ostial stenosis has been reported in 2% to 40% of cases, and the left inferior pulmonary vein (LIPV) is at higher risk. The prevalence of arrhythmogenic foci is higher in the superior PVs compared to the inferior PVs, and the left superior pulmonary vein (LSPV) is the vein with the longest muscular sleeve. Therefore, ablation strategies targeting the superior PVs appear as attractive options in this clinical setting.
We hypothesized that in patients with PAF, isolation of the LSPV only at the initial ablation attempt, followed by isolation of the right superior pulmonary vein (RSPV) in cases of AF recurrence instead of targeting of all veins, might simplify the ablation approach without significant reduction in the success rate of the procedure. Therefore, we conducted a prospective randomized trial of single LSPV isolation followed by additional RSPV isolation in case of AF recurrence compared to ablation of all four PVs for treatment of patients with PAF. To our knowledge, this is the first time such a randomized comparison has been conducted.
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