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Magnetic Resonance Imaging‐Confirmed Ablative Debulking of the Left Atrial Posterior Wall and Septum for Treatment of Persistent Atrial Fibrillation: Rationale and Initial Experience
Author(s) -
SEGERSON NATHAN M.,
DACCARETT MARCOS,
BADGER TROY J.,
SHABAAN AKRAM,
AKOUM NAZEM,
FISH ERIC N.,
RAO SWATI,
BURGON NATHAN S.,
ADJEIPOKU YAW,
KHOLMOVSKI EUGENE,
VIJAYAKUMAR SATHYA,
DIBELLA EDWARD V.R.,
MACLEOD ROB S.,
MARROUCHE NASSIR F.
Publication year - 2010
Publication title -
journal of cardiovascular electrophysiology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.193
H-Index - 138
eISSN - 1540-8167
pISSN - 1045-3873
DOI - 10.1111/j.1540-8167.2009.01611.x
Subject(s) - medicine , ablation , pulmonary vein , atrial fibrillation , magnetic resonance imaging , cardiology , catheter ablation , hazard ratio , radiofrequency ablation , debulking , radiology , confidence interval , cancer , ovarian cancer
LA Debulking for Atrial Fibrillation.Introduction:Though pulmonary vein (PV) isolation has been widely adopted for treatment of atrial fibrillation (AF), recurrence rates remain unacceptably high with persistent and longstanding AF. As evidence emerges for non‐PV substrate changes in the pathogenesis of AF, more extensive ablation strategies need further study.Methods:We modified our PV antrum isolation procedure to include abatement of posterior and septal wall potentials. We also employed recently described image‐processing techniques using delayed‐enhancement (DE) MRI to characterize tissue injury patterns 3 months after ablation, to assess whether each PV was encircled with scar, and to assess the impact of these parameters on procedural success.Results:118 consecutive patients underwent debulking procedure and completed follow‐up, of which 86 underwent DE‐MRI. The total left atrial (LA) radiofrequency delivery correlated with percent LA scarring by DE‐MRI (r = 0.6, P < 0.001). Based on DE patterns, complete encirclement was seen in only 131 of 335 PVs (39.1%). As expected, Cox regression analysis showed a significant relationship between the number of veins encircled by delayed enhancement and clinical success (hazard ratio of 0.62, P = 0.015). Also, progressive quartile increases in postablation posterior and septal wall scarring reduced recurrences rates with a HR of 0.65, P = 0.022 and 0.66, P = 0.026, respectively.Conclusion:Pathologic remodeling in the septal and posterior walls of the LA helps form the pathogenic substrate for AF, and these early results suggest that more aggressive treatment of these regions appears to correlate with improved ablation outcomes. Noninvasive imaging to characterize tissue changes after ablation may prove essential to stratifying recurrence risk. (J Cardiovasc Electrophysiol, Vol. 21, pp. 126‐132, February 2010)