COMPARISON OF EFFECTIVENESS OF GANGLIONICIC PLEXUS ABLATION AND LINEAR APPLICATIONS IN ADDITION TO PULMONARY VEIN ISOLATION IN PATIENTS WITH PERSISTENT AND LONG-LASTING PERSISTENT ATRIAL FIBRILLATION

To compare safety and effectiveness of pulmonary vein isolation (PVI) in combination with linear ablation (LA) or ganglionic plexus ablation (GPA), 264 patients with persistent and long-lasting persistent atrial fibrillation (AF) were examined and surgically treated. The patients were randomized into two following groups: PVI+LA (n=132) and PVI+GPA (n=132). The primary endpoint was freedom from any atrial tachyarrhythmia including AF, atrial flutter, and atrial tachycardia after the first ablative procedure recorded by loop recorders. The “blind period” data obtained within first 3 months following ablation was excluded from analysis. The circular PVI was performed to the patients of both groups. The anatomic area of GPA was determined by vagus response to overdrive pacing with the amplitude of 15 W, duration of 10 ms, frequency of 20 50 Hz, and duration of pacing up to 5 s. Target areas also included adjacent areas with complex fractionated atrial electrograms detected. In the PVI+LA group, ablative lines were made which connected the left inferior pulmonary vein with the mitral valve annulus (the left isthmus), as well as the line of the left atrium roof between two superior pulmonary veins. In 132 patients of the PVI+GPA group, 5.6±0.4 applications for each target area were made, additional 8.9±2.7 radiofrequency applications were performed in the areas with complex fractionated atrial electrograms. For each patient, the total number of 64.7±3.8 radiofrequency applications in the ganglionic plexus areas was carried out. The complete electric PVI and the cavo-tricuspid conduction block were achieved in all 264 subjects of both study groups. The duration of radiofrequency application was 58±11 min in the PVI+LA group and 69±4 min in the PVI+GPA group (p<0.001), the duration of procedure and X-ray exposure in the PVI+GPA group was longer than in the PVI+LA group (192±21 min and 153±37 min, respectively, p<0.001; 34±11 min and 29±15 min, respectively, p=0.002). After the single ablative procedure, during a 12 month follow-up period, 71 patients (54%) from the PVI+GPA group were free of atrial fibrillation/flutter/tachycardia as compared with 62 patients (47%) from the PVI+LA group (p=0.29). After 36 months of follow-up, 65 patients (49%) from the PVI+GPA group and 45 patients (34%) from the PVI+LA group were free of atrial fibrillation/flutter/tachycardia (p=0.035). The patients of both groups did not take antiarrhythmics. The percentage of patients with the left atrial flutter was significantly higher in the PVI+LA group than in the PVI+GPA group and made up 18% (24 patients) and 6% (8 patients), respectively (p=0.002). The number of AF recurrence (excluding atrial flutter) did not significantly differ in the study groups: 56 patients (42%) in the PVI+GPA group and 50 patients (38%) in the PVI+LA group after 12 months of follow-up (p=0.71) and 59 patients (45%) in the PVI+GPA group and 63 patients (48%) in the PVI+LA group after 36 months of follow-up (p=0.44). Within the follow-up period of 28.4±14.4 months, recurrence of atrial fibrillation/flutter/tachycardia occurred in 154 patients (58%). Re-ablation was carried out in 78 patients (59%) from the PVI+LA group and 55 patients (42%) from the PVI+GPA group (p=0.002). Other 21 patients (16%) with recurrence of atrial fibrillation/flutter/tachycardia refused of the repetitive procedure. After re-ablation, the procedure effectiveness in patients free of antiarrhythmic therapy was 68% in the PVI+GPA group and 52% in the PVI+LA group (p=0.006). Thus, in patients with persistent AF, PVI+GPA is a more promising technique than PVI+LA.

atrial fibrillation, radiofrequency pulmonary vein isolation, ganglionic plexus ablation, linear ablation, areas with complex fractionated atrial electrograms, loop recorder

1. Calkins Н., Kuck K-H, Cappato R., et al. 2012 HRS/ EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation//Heart Rhythm. 2012; 9(4): 632-696

2. Cappato R, Calkins H, Chen S, et al. Updated Worldwide Survey on the Methods, Efficacy, and Safety of Catheter Ablation for Human Atrial Fibrillation // Circ Arrhythm Electrophysiol. 2010; 3: 32-38.

3. Brooks AG, Stiles MK, Laborderie J, et al. Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review // Heart Rhythm. 2010; 7: 835-846.

4. Sawhney N, Anousheh R, Chen W, et al. Circumferential pulmonary vein ablation with additional linear ablation results in an increased incidence of left atrial flutter compared with segmental pulmonary vein isolation as an initial approach to ablation of paroxysmal atrial fibrillation // Circ Arrhythm Electrophysiol. 2010; 3: 243-248.

5. Katritsis DG, Giazitzoglou E, Pokushalov E, et al. Rapid pulmonary vein isolation combined with autonomic ganglia modification: a randomized study // Heart Rhythm. 2011; 8: 672-8.

6. Zhou Q, Hou Y, Yang S. A Meta-Analysis of the Comparative Efficacy of Ablation for Atrial Fibrillation with and without Ablation of the Ganglionated Plexi // Pacing Clin Electrophysiol. 2011; 34: 1687-94.

7. Pokushalov E, Romanov A, Artyomenko, et al. Ganglionated plexi ablation for longstanding persistent atrial fibrillation // Europace. 2010; 12: 342-6.

8. Pokushalov E, Romanov A, Corbucci G, et al. Ablation of paroxysmal and persistent atrial fibrillation: 1-year follow-up through continuous subcutaneous monitoring // J Cardiovasc Electrophysiol 2011; 22: 369-75.

9. Pokushalov E, Romanov A, Po SS, et al. Ganglionated plexi ablation directed by high-frequency stimulation and complex fractionated atrial electrograms for paroxysmal atrial fibrillation // Pacing Clin Electrophysiol. 2012; 35: 776-84.

10. Lemery R, Birnie D, Tang A, et al. Feasibility study of endocardial mapping of ganglionated plexuses during catheter ablation of atrial fibrillation // Heart Rhythm 2006; 3: 387-396.

11. Nademanee K, Schwab M, Porath J, et al. How to perform electrogram-guided atrial fibrillation ablation // Heart Rhythm. 2006. 3(8): 981-4.

12. Hindricks G, Pokushalov E, Urban L, et al. XPECT Trial Investigators. Performance of a new leadless implantable cardiac monitor in detecting and quantifying atrial fibrillation: Results of the XPECT trial // Circ Arrhythm Electrophysiol 2010; 3: 141-7.

13. Katritsis D, Wood MA, Giazitzoglou E, et al. Long term follow-up aper radiofrequency catheter ablation for atrial fibrillation // Europace. 2008; 10: 419-24.

14. Pokushalov E, Romanov A, Steinberg JS, et al. Does atrial fibrillation burden measured by continuous monitoring during the blanking period predict the response to ablation at 12-month follow-up? // Heart Rhythm. 2012 (in press).

15. Pokushalov E, Romanov A, Artyomenko S, et al. Left Atrial Ablation at the Anatomic Areas of Ganglionated Plexi for Paroxysmal Atrial Fibrillation // Pacing Clin Electrophysiol. 2010; 33: 1231-8.

16. Katritsis D, Giazitzoglou E, Sougiannis D, et al. Anatomic approach for ganglionic plexi ablation in patients with paroxysmal atrial fibrillation // Am J Cardiol. 2008; 102: 330-4.

17. Pokushalov E, Romanov A, Shugayev P, et al. Selective ganglionated plexi ablation for paroxysmal atrial fibrillation // Heart Rhythm 2009; 6: 1257-64.

18. Pokushalov E, Romanov A, Artyomenko S, et al. Ganglionated plexi ablation for longstanding persistent atrial fibrillation // Europace. 2010; 12: 342-6.

19. Van Brakel TJ, Bolotin G, Nifong LW, et al. Robot-assisted epicardial ablation of the pulmonary veins: is a completed isolation necessary? // Eur Heart J. 2005; 26: 1321-6.

20. Rostock T, O’Neill MD, Sanders P, Rotter M, Jaïs P, Hocini M, Takahashi Y, Sacher F, Jönsson A, Hsu LF, Clémenty J, Haïssaguerre M. Characterization of conduction recovery across left atrial linear lesions in patients with paroxysmal and persistent atrial fibrillation. J. Cardiovasc Electrophysiol. 2006; 17: 1106-11.

21. Hayward RM, Upadhyay GA, Mela T, et al. Pulmonary vein isolation with complex fractionated atrial electrogram ablation for paroxysmal and nonparoxysmal atrial fibrillation: A meta-analysis // Heart Rhythm. 2011; 8: 9941000.