Prevalence of pulmonary vein disconnection after anatomical ablation for atrial fibrillation: consequences of wide atrial encircling of the pulmonary veins

Abstract

Aims Anatomical and wide atrial encircling of the pulmonary veins (PVs) has been proposed as a cure of atrial fibrillation (AF). We evaluated the acute achievement of electrical PV isolation using this approach. In addition, the consequences of wide encircling of the PVs with isolation were assessed. Methods and results Twenty patients with paroxysmal AF were studied. Anatomically guided ablation was performed utilizing the CARTO system to deliver coalescent lesions circumferentially around each PV to produce a voltage reduction to ,0.1 mV, with the operator blinded to recordings of circumferential PV mapping. After achieving the anatomical endpoint, the incidence of residual conduction and the amplitude and conduction delay of residual PV potentials were determined. Electrical isolation of the PV was then performed and the residual far-field potentials evaluated. Individual PV ablation was performed in all PVs. Anatomically guided PV ablation was performed for 47.3+11 min, after which 44 (55%) PVs were electrically isolated. In the remaining 45%, despite abolition of the local potential at the ablation site, PV potentials [amplitude 0.2 mV (range 0.09–0.75) and delay of 50.3+12.6 ms] were identified by circumferential mapping. After electrical isolation (12.2+11.7 min ablation), 55 (69%) PVs demonstrated far-field potentials; with a greater incidence (P ¼ 0.015) and amplitude (P ¼ 0.021) on the left compared with the right PVs. At 13.2+8.3 months follow-up, 13 patients (65%) remained arrhythmia-free without anti-arrhythmics. In four patients (20%), spontaneous sustained left atrial macrore-entry required re-mapping and ablation. Macrore-entry was observed to utilize regions around or bordering the previous ablation as its substrate. Conclusion Anatomically guided circumferential PV ablation results in apparently coalescent but electrically incomplete lesions with residual conduction in 45% of PVs. Wide encircling of the PVs was associated with left atrial macrore-entry in 20% of patients.