LONG-TERM OUTCOMES OF EXTENDED PULMONARY VEIN ANTRUM ISOLATION IN PERSISTENT ATRIAL FIBRILLATION

To assess long-term outcomes of extended pulmonary vein isolation for treatment of persistent atrial fibrillation, 210 patients aged 55.6±8.9 years with symptomatic persistent atrial fibrillation (EHRA class 3.4±0.2) resistant to antiarrhythmic therapy for 4.8±3.0 years were examined and treated. Aim: Assessment of long-term outcomes extended pulmonary vein (PV) isolation for treatment of persistent atrial fibrillation (AF). Methods: The study included 210 subjects with symptomatic persistent AF resistant to antiarrhythmic therapy. The subjects were randomized for treatment in three following groups: pulmonary vein antrum isolation (PVAI; n=68), extended pulmonary vein antrum isolation (EPVAI; n=75), or ganglionic plexus ablation (GPA; n=67). We assessed the parameters short-term outcomes of the procedures. The time course of the left atrium (LA) mechanical function and the level of N-terminal fragment of precursor brain-type natriuretic peptide (NT ProBNP) were also assessed. The assessment of clinical effect of the procedure was based on the subjects’ self-assessment and the results of 7 day Holter monitoring. The primary effectiveness endpoint was freedom from AF after ablation. The follow-up period of the study subjects was 5 years. Results: Both the procedure duration and the overall duration of all applications in the GPA group were shorter. An increased duration of all applications in the EPVAI group did not significantly affect the overall duration of the procedure. Three months following the procedure, the GPA group was characterized by the most favorable results of self-assessment; later on, no differences were detected. 12-36 months following the procedure, the number of patients with the optimal effect prevailed in the EPVAI group. The AF recurrence rate in the EPVAI group was significantly lower. Thus, by the fifth year after the procedure, freedom from atrial arrhythmias was 58% in the EPVAI group, 35% in the PVAI group, and 22% in the GPA group (p=0.0114). The positive correlation between the LA ablation area and the long-term clinical effectiveness was also revealed. The PVAI and EPVAI groups were characterized by a significant decrease in reservoir and contractile functions of LA, especially if the ablation area was more than 25%. No significant increase in the NT ProBNP level was found; it indicates that changes in the LA mechanical function did not have an impact on the central hemodynamics. Conclusions: The long-term clinical effectiveness of primary EPVAI in persistent AF is significantly better than of PVAI and GPA. The GPA group was characterized by the lowest number of post-ablation arrhythmias. The PVAI and EPVAI groups were characterized by a similar incidence of post-ablation arrhythmias.

atrial fibrillation, radiofrequency ablation, left atrium, pulmonary veins, pulmonary vein antrum isolation

1. A Tailored Approach to Catheter Ablation of Paroxysmal Atrial Fibrillation / H. Oral [et al.] // Circulation. - 2006. - Vol. 113(15). - P. 1824-1831.

2. Circumferential radiofrequency ablation of pulmonary vein ostia: A new anatomic approach for curing atrial fibrillation / C. Pappone [et al.] // Circulation. - 2000. - Vol. 102(21). - P. 2619-2628.

3. Circumferential pulmonary-vein ablation for chronic atrial fibrillation / H. Oral [et al.] // N. Engl. J. Med. - 2006. - Vol. 354(9). - P. 934-941.

4. Prevention of iatrogenic atrial tachycardia after ablation of atrial fibrillation: a prospective randomized study comparing circumferential pulmonary vein ablation with a modified approach / C. Pappone [et al.] // Circulation. - 2004. - Vol. 110(19). - P. 3036-3042.

5. Ganglionated plexi ablation for longstanding persistent atrial fibrillation / E. Pokushalov [et al.] // Europace. - 2010. - Vol. 12(3). - P. 342-346.

6. Nademanee K. The role of complex fractionated atrial electrograms in atrial fibrillation ablation moving to the beat of a different drum / K. Nademanee, N. Oketani // J. Am. Coll. Cardiol. - 2009. - Vol. 53(9). - P. 790-791.

7. Radiofrequency catheter ablation of atrial fibrillation guided by spectral mapping of atrial fibrillation nests in sinus rhythm / J.C. Mateos [et al.] // Arq. Bras. Cardiol. - 2007. - Vol. 89(3). - P. 124-134, 140-150. [Article in English, Portuguese].

8. Approaches to catheter ablation for persistent atrial fibrillation / A. Verma [et al.] // N. Engl. J. Med. - 2015. - Vol. 372(19). - P. 1812-1822.

9. ‘Electrical exclusion’ of a critical myocardial mass by extended pulmonary vein antrum isolation for persistent atrial fibrillation treatment / S.E. Mamchur [et al.] // Interv. Med. Appl. Sci. - 2014. - Vol. 1. - P. 31-39.

10. Расширенная антральная изоляция легочных вен -новый способ лечения фибрилляции предсердий / С.Е. Мамчур [и др.] // Вестник аритмологии. - 2011. - № 65. - С. 33-38.

11. Moe, G.K. Atrial fibrillation as a self-sustaining arrhythmia independent of focal discharge / G.K. Moe, J.A. Abildskov // Amer. Heart J. - 1959. - Vol. 58. - P. 59-66.

12. West, T.C. Minimal mass required for induction of a sustained arrhythmia in isolated atrial segments / T.C. West, J.F. Landa // Amer. J. Physiol. - 1962. - Vol. 202, № 1. - Р. 232-236.

13. Shen, J. The Surgical Treatment of Atrial Fibrillation / J. Shen, M.S. Bailey, R.J. Damiano // Heart Rhythm. -2009. - Vol. 6 (8 Suppl). - P. S45-S50.

14. Оферкин, А. И. Изучение механизмов фибрилляции предсердий. IV. Разработка новых способов хирургической коррекции фибрилляции предсердий / А.И. Оферкин, А.И. Петш, Е.А. Покушалов // Вестн. аритмологии. - 2008. - Т. 39, Прил. А. - С. 39.

15. Оферкин, А.И. Необходимый объем и локализация гомогенных повреждений при аблации фибрилляции предсердий. III. Функциональная критическая площадь предсердий / А.И. Оферкин // Вестн. аритмологии. - 2008. - Т. 39, Прил. А. - С. 40.

16. Gibson, D.N. Stiff left atrial syndrome after catheter ablation for atrial fibrillation: Clinical characterization, prevalence, and predictors / D.N. Gibson // Heart Rhythm. - 2011. - Feb. 23.

17. Atrial stunning masquerading as restrictive Doppler flow pattern: a case of mitral inflow «pseudorestriction» / G.P. Kelley [et al.] // Echocardiography. - 2006. - Vol. 23(2). - P. 172-175.

18. Yamada, H. The pseudorestrictive pattern of transmitral Doppler flow pattern after conversion of atrial fibrillation to sinus rhythm: is atrial or ventricular dysfunction to blame? / H. Yamada, E. Donal, Y.J. Kim // J. Am. Soc. Echocardiogr. - 2004. - Vol. 17 (8). - P. 813-818.

19. Ablation of atrial fibrillation: does the addition of three-dimensional magnetic resonance imaging of the left atrium to electroanatomic mapping improve the clinical outcome? / D. Caponi [et al.] // Europace. - 2010. - Vol. 12. - P. 1098-1104.19