Michalis EfremidisElectrophysiological LABSecond Department of Cardiology‘‘Evangelismos’’ Hospital Athens

PAF Without atrial myopathy

PAF With atrial myopathy

Persistent AF Without atrial myopathy

Persistent AF With atrial myopathy

• 14.5% of the pts with AF Recurrence had all PVs

isolated

• 58.6% of the pts with SR maintenance had at least

1 PV reconnected

J Am Coll Cardiol EP 2016;2:723–31

26 patients had persistent PVI out of 63 pts undergoing redo procedure

(41%) [in 300 pts with initial AF ablation 41% pers AF]

N Engl J Med 2015;372:1812-22Atul Verma

N Engl J Med 2015;372:1812-22Atul Verma

1st Limitation

Not all CFAEs are the same

CFAEs characterized by the following EGMs:(1) low-voltage (range0.04–0.25 mV) signals that

have multiple potentials with continuousdeflection of a prolonged activation complex

(2) stationary CFAEs that have temporal andspatial stability

(3) short–cycle length (CCL 50–120 ms) EGMsthat occur repeatedly with a relatively stablefrequency with or without multiplepoten-tials as CFAEs

Oketani et al Heart Rhythm 2016

2nd Limitation

The common CFAE sites of STAR AF II arelocated in the posterior wall close to the roofand in the middle of the posterior wall; theseare not the usual sites we ablate. Our commonsites are typically at the antra of PVs, septalwall, posterior mitral annulus, mouth or atrialappendage, and coronary sinus.

Oketani et al Heart Rhythm 2016

Randomized studies using operators who perform the technique regularly in their laboratories to compare this technique with other ablative approaches

3nd Limitation

4th Limitation: At the time of ablation, 79% of patients were in spontaneousatrial fibrillation

5th Limitation: For the group assigned to isolation plus lines, all patients had therequired lines performed, with 74% showing complete conduction block acrossboth lines

6th Limitation: Complex fractionated electrograms were successfully eliminated in80% of patients

7th Limitation: Rates of freedom from atrial fibrillation after two ablationprocedures, with or without antiarrhythmic medication, were not significantlydifferent among groups

N Engl J Med 2015;372:1812-22Atul Verma

There was a significant difference in AF termination between randomization arms: 5% for PVI, 40.2% for PVI plus CFAE, and 17.2% for PVI plus linear ablation (P 0.001).

Simon Kochhäuser Heart Rhythm2017;14:476–483

Heart Rhythm2017;14:476–483 Simon Kochhäuser

CONCLUSION Acute AF termination and prolongation in AFCL did not consistently predict 18-month freedom from AF.!!!! Presence of SR before orearly during the ablation was the strongestpredictor of better outcome

If AF terminated in to atrial tachycardia or atrial flutter during ablation, the decision to map and ablate the tachycardia or cardiovert was left to the investigator’s discretion ????

J Am Coll Cardiol 2015;66:2743–52

!!!!!!!!

Τhe longest episode of continuous AF had been <12 months in most patients.

Circ Arrhythm Electrophysiol. 2016

Heart Rhythm2016;0:1–7

Initial ablation procedure: The termination site was the PV antrum (24pts 18%), LA (35pts 26%), and RA 10 pts 7%

Circ Arrhythm Electrophysiol. 2015;8:18-24.Daniel Scherr

AF termination in Persistent atrial fibrillation

ablationEvangelismos EP Lab

PVAI is effective in pts with Pers AF presenting with SR without atrial

myopathy

PVAI + extra PV ablation is the optimal approach for pts with Pers AF

presenting with AF, without atrial myopathy

AF termination with PVAI + LA and RA substrate modification is the

optimal approach in pts with Pers AF presenting with AF and atrial

myopathy

Atrial myopathy is a progressive disease? So AF elimination with AF

ablation probably is not a long term cure?