Cardiac Rhythm Management
Articles Articles 2010 October


John Day, MD, FACC, FHRS


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The Journal of Innovations in Cardiac Rhythm Managemen
Director of Heart Rhythm Services
Intermountain Medical Center, Salt Lake City, UT



Dear Readers,

I hope that you enjoyed the inaugural issue of The Journal of Innovations in Cardiac Rhythm Management last month. On behalf of our editorial board and publishers, I would like to offer a heartfelt thank you for the great response we have received thus far. It is our goal to continually provide compelling content each month through both the print publication and our interactive website, which strive to enhance your daily practice. We have a great second issue that is sure to build upon our inaugural issue's success!

The basis of this month's installment of my letter is a featured article within this current issue, Redo Procedures in Patients with Paroxysmal Atrial Fibrillation by Dr. Sarina A. van der Zee and Dr. Andre d'Avila of Mount Sinai Hospital.

The article elegantly outlines a systematic approach for the effective management of paroxysmal AF patients suffering a recurrence. Unfortunately, approximately 1 in 3 patients undergoing AF ablation will ultimately require a redo procedure.

Although the authors identify a number of risk factors for AF recurrence including age, left atrial size, persistent AF, hypertension, sleep apnea, obesity, and hypertrophic cardiomyopathy, redo procedures are often required, even for the simple paroxysmal AF due to pulmonary vein reconnection. Indeed, as the authors point out, more than 95% of the redo cases involve reconnection of at least one pulmonary vein. In addition to pulmonary vein reconnection, they discuss other causes of ongoing atrial arrhythmias, which include non-pulmonary vein trigger, left atrial flutters, and typical right atrial flutter.

The real question here is: what can be done to avoid the need for a redo AF procedure? This is really the “Holy Grail” of AF ablation therapy. Over the years, our center has performed more than 3,000 AF ablation procedures. Our technique has evolved in part to avoid or minimize the risk of a redo procedure. Currently, our approach with the first AF ablation procedure in the paroxysmal AF patient and persistent AF of short duration is as follows to avoid a redo procedure:

1. We ensure durable pulmonary vein antrum isolation. This not only includes entrance and exit block within the pulmonary veins, but also ablation of all local electrograms within the pulmonary vein antrum. Special attention, including additional ablation lesions, is required to sites where reconnection typically occurs, which is on the superior portion of the veins, the carina between the upper and lower veins, the inferior portion of the veins, and the ridge between the left atrial appendage and the left-sided veins. We will wait at least 30 minutes after pulmonary vein antrum isolation to ensure that entrance and exit block is still intact.
2. We perform a left atrial roof line in all patients and ensure left atrial roof block. We have found over the years that left atrial roof flutters may occur in 5–10% of our patients over 5 years of follow-up, particularly if it is a very wide area ablation approach.
3. We perform a cavo-tricuspid flutter ablation in all patients and ensure bidirectional block. Once again, we have found that if this is not targeted, 10–20% of patients will develop a typical flutter over 5 years of follow-up, even if they did not have a history of right atrial flutter or inducible right atrial flutter at the time of their initial procedure.
4. We avoid the mitral isthmus flutter ablation (including the left atrial anterior line to create block around the mitral valve) unless there is clearly an inducible mitral flutter. We have found that the number 1 predictor of later encountering a mitral flutter is to perform the mitral flutter ablation line.
5. We will ablate any other focal AF trigger or other inducible arrhythmias at the time of the first procedure.
6. In general, we avoid CFE ablation with the first procedure to minimize the long-term risk of left atrial flutter/tachycardia.

The key take-home message here is that when performing the index AF ablation case, special care needs to be taken to maximize the first procedure success and to avoid future left atrial flutters and tachycardias. Sadly, if a patient develops an atrial flutter/tachycardia after an AF ablation procedure, it is more often symptomatic than the initial AF.

I hope that you enjoy the second issue of Innovations in CRM. You, the readers, inspire everything we do, and we look forward to your continued feedback. Your input and contributions are instrumental in allowing us to produce the best journal and complementary web platforms possible!