Short- and long-term experience in pulmonary vein segmental ostial ablation for paroxysmal atrial fibrillation*



Purerfellner H., Aichinger J., Martinek M., Nesser H.J., Janssen J,                    12

Short- and long-term experience in pulmonary vein segmental ostial ablation for
paroxysmal atrial fibrillation”

Complications

Significant PV stenoses are the leading cause of side effects in the longterm follow up
ranging up to 7.7% (n=9), all other complications account for less than 1.5%, such as pericardial
tamponade (n=2), pericardial effusion (n=2), stroke (n=2), pneumo-/hemothorax (n=2), groin
hematoma (n=2) and pericarditis (n=1). In total, 20 patients (17.1%) had either a single or 2 (3
patients, 2.6%) complications independent of the number of procedures performed.

Discussion

We have reported repeatedly on our experience in ostial PVI recently, in particular on the
occurence of PV stenosis
6,7 , quality of life8 and the evaluation of procedural success by use of
longterm implantable monitoring provided by special implantable pacemakers with extended
storage capabilities in chronically paced patients
9.

In this paper our data highlight the potentially curative therapeutic approach of segmental
ostial PVI over a short- and longterm follow up in a patient cohort with highly symptomatic and
medically drug-refractory recurrent PAF and without significant underlying heart disease. In
total, 78% of patients show a clinical benefit over a follow up period of 6 months, which is
reduced to 62% in the long-term after approximately 24 months in a patient cohort that
underwent PVI in 3 PVs (sparing the RIPV). An ablation procedure that includes PVI in the
RIPV as well exhibits a higher curative success rate after 6 months of follow up (54% versus
44%).

Segmental ostial PVI

According to current knowledge, a segmental ostial ablation approach at the PV-LA
junction represents a predominant trigger elimination of ectopic foci from within the PVs
capable of initiating PAF by rapid focal discharges. To which extent an ongoing fibrillatory
process in the LA may be maintained by such PV discharges remains an open issue at this point
in time
10. In addition, ectopic activity that may trigger PAF may also be generated at different
sites in both atria (posterior and anterior LA, coronary sinus, terminal crest, superior caval vein).
This may well explain why a 100% cure rate is unlikely when applying radiofrequency ablation
at the ostial level of the PVs solely.

Procedural parameters

Despite the fact that the arrhythmogenic potential of the RIPV was somewhat in doubt
years ago, our results are in accordance with other more recent reports in the literature
demonstrating the importance of implementing this PV in the ablation procedure. As illustrated
in
figure 3 the CS is higher when isolating all 4 PVs (versus 3 PVs). The RIPV is sometimes
more difficult to reach technically, however, with improved catheter steerability this problems is
solved most of the time nowadays. Other procedural parameters do not seem crucial in our series
as our approach of isolating the PVs did not change over the years using the same diagnostic
catheter (Lasso catheter) within the PV ostium and a stable energy source for ablation
(radiofrequency ablation with irrigated catheters) with unchanged energy settings (30 Watts for
the superior PVs and 20-25 Watts for the inferior PVs).

Longterm success rate

Our longterm success rates after approximately 24 months may be limited by the fact that
these results represent the outcome in patients having undergone ostial PVI in 3 PVs exclusively.
If we compare the longterm success rate of this separted group with its 6 month follow up data,
it is obvious that the CS is literally idenitical (41%) whereas the PS and the CRR seem to be
somewhat higher on a short term basis (33% versus 21% and 74% versus 62%, respectively).

Indian Pacing and Electrophysiology Journal (ISSN 0972-6292), 6(1): 6-16 (2006)



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