Ablation of Persistent and Long Lasting Persistent Atrial Fibrillation

John R Onufer MD FHRS

New Classification of Atrial Fibrillation

Paroxysmal (that which terminates spontaneously)

Persistent Sustained > 7 days, or lasting < 7 days but requires pharmacologic or electrical cardioversion treatment

Long lasting persistent: That which may last longer than 7 days but plans to convert to nsr

Permanent No longer plan to return to NSR (chronic afib is no longer a term)

Stepwise approach 1. PV isolation: PV isolation alone is a

50-20% Success (afib <1 year associated with higher success)

2. Linear lesions with pv isolation (Willems: 69 vs 20% mean fu 487 days) Roof between lspv and rspv LIPV to Mitral annulus TV-IVC

Stepwise approach 3. CFAEs: Definition variable

120 msec. but not clearly associated with areas of scar.

Variable results 4. Non Pulmonary Foci;

Ligament of Marshall SVC Mitral annulus CS Crista terminalis LA posterior wall LA appendage

Bordeaux experience 38% Drug free success at 20 months 81% if perform multiple procedures Termination of afib during ablation for

persistent and long standing persistent afib predictive of higher success rate.

Critical to confirm pv isolation and Integrety of lines after conversion to nsr 86% terminate to atach or aflutter (focal,

macro reentrant, localized reentry)

Cost of More Extensive procedures

Higher complication rate Longer procedure times Higher rate of post procedure atrial

tachycardias Longer fluro times

Patient Selection Higher rates of recurrance:

LA size greater than 4.3 cm Pulmonary disease Duration of afib Valvular heart disease

Hybrid Afib ablation

Hrs Guidelines Careful identification of the PV ostia is mandatory

to avoid ablation within the PVs. If a focal trigger is identified outside a PV at the

time of an AF ablation procedure, ablation of that focal trigger should be considered.

If additional linear lesions are applied, operators should consider using mapping and pacing maneuvers to assess for line completeness.

Ablation of the cavotricuspid isthmus is recommended in patients with a history of typical atrial flutter or inducible cavotricuspid isthmus dependent atrial flutter.

HRS Guidelines If patients with long standing persistent

AF are approached, operators should consider more extensive ablations based on linear lesions or complex fractionated electrograms

It is recommended that RF power be reduced when creating lesions along the posterior wall near the esophagus

Summary:Ablation of Long lasting

persistent atrial fibrillation 1. Remains a challenge 2. There is no uniform procedure

PV antral isolation superior to pv wide area encircling lesions with voltage abatement

CFAE ablation alone inferior to PVAI and linear lesions No incremental benefit to right atrial CFAE ablation

(routinely) CFAE ablation may or may not provide incremental

benefit when added to PVAI. 3. Risk/Benefit for any patient has to be carefully

considered 4. Long term outcomes need to be evaluated in

randomized trials

Thank you