Effect of Empirical Left Atrial Appendage Isolation on Long-term Procedure Outcome in Patients With Persistent or Long-standing Persistent Atrial Fibrillation Undergoing Catheter Ablation
| Status: | Completed |
|---|---|
| Conditions: | Atrial Fibrillation |
| Therapuetic Areas: | Cardiology / Vascular Diseases |
| Healthy: | No |
| Age Range: | 18 - 75 |
| Updated: | 4/27/2017 |
| Start Date: | November 2010 |
| End Date: | November 2016 |
The purpose of this prospective randomized study is to assess whether empirical Left Atrial
Appendage (LAA) isolation along with the standard approach of pulmonary vein isolation (PVI)
and ablation of extra-pulmonary triggers is superior to the standard approach alone in
enhancing the long-term success rate of catheter ablation in persistent or long-standing
persistent atrial fibrillation (AF) patients.
Appendage (LAA) isolation along with the standard approach of pulmonary vein isolation (PVI)
and ablation of extra-pulmonary triggers is superior to the standard approach alone in
enhancing the long-term success rate of catheter ablation in persistent or long-standing
persistent atrial fibrillation (AF) patients.
Persistent (PeAF) and long-standing persistent (LSP) AF are defined as sustained AFs
extending beyond seven days and one year respectively (1). Hypertensive, ischemic, valvular
and other structural heart diseases most commonly underlie these arrhythmias (2) and the
resulting abnormal atrial substrate is believed to be the major contributor toward
perpetuation of AF in these non-paroxysmal categories. Several studies have demonstrated
that pulmonary vein isolation (PVI) by radiofrequency catheter ablation (RFCA) though
successfully restores sinus rhythm in most patients with paroxysmal AF; it has limited
success in these sustained arrhythmias (3). Presence of potential trigger-generating areas
in the left and right atrium besides pulmonary veins, with reported incidence from 3.2% to
47% (4), can be held responsible for this limited success. These areas include superior vena
cava, ligament of Marshall, crista terminalis, coronary sinus, left atrial (LA) posterior
wall and LA appendage (3). Therefore, in order to enhance the procedural-success rate,
various hybrid measures have emerged to target the PV as well as extra-PV areas that have
the ability to initiate or maintain AF. Several previous studies have demonstrated the
prevalence of LAA firing in patients with recurrence of AF/AT (atrial tachycardia) after
catheter ablation of AF (4). Embryologically, LAA is the remnant of primitive LA, which is
formed by the adsorption of primordial PV and their branches during 4th week of embryonic
development. Therefore, it is logical to suggest that LAA may initiate AF like pulmonary
veins. In an earlier study conducted by our group on 987 AF patients, LAA firing was
revealed to be the source of AF in 27% of patients and 93% of those patients were arrhythmia
free 6 months after LAA isolation (4).
Our study aims to compare the procedure outcome for two different ablation strategies; 1)
standard approach of pulmonary vein isolation extended to the posterior wall down to the
coronary sinus and to the left side of the interatrial septum along with isolation of
superior vena cava and ablation of complex fractionated atrial electrograms (CFAE) in the
atria and coronary sinus, 2) standard approach plus LAA isolation.
Hypothesis: LAA isolation combined with standard ablation procedure enhances the procedural
success rate in non-paroxysmal AF patients undergoing catheter ablation.
extending beyond seven days and one year respectively (1). Hypertensive, ischemic, valvular
and other structural heart diseases most commonly underlie these arrhythmias (2) and the
resulting abnormal atrial substrate is believed to be the major contributor toward
perpetuation of AF in these non-paroxysmal categories. Several studies have demonstrated
that pulmonary vein isolation (PVI) by radiofrequency catheter ablation (RFCA) though
successfully restores sinus rhythm in most patients with paroxysmal AF; it has limited
success in these sustained arrhythmias (3). Presence of potential trigger-generating areas
in the left and right atrium besides pulmonary veins, with reported incidence from 3.2% to
47% (4), can be held responsible for this limited success. These areas include superior vena
cava, ligament of Marshall, crista terminalis, coronary sinus, left atrial (LA) posterior
wall and LA appendage (3). Therefore, in order to enhance the procedural-success rate,
various hybrid measures have emerged to target the PV as well as extra-PV areas that have
the ability to initiate or maintain AF. Several previous studies have demonstrated the
prevalence of LAA firing in patients with recurrence of AF/AT (atrial tachycardia) after
catheter ablation of AF (4). Embryologically, LAA is the remnant of primitive LA, which is
formed by the adsorption of primordial PV and their branches during 4th week of embryonic
development. Therefore, it is logical to suggest that LAA may initiate AF like pulmonary
veins. In an earlier study conducted by our group on 987 AF patients, LAA firing was
revealed to be the source of AF in 27% of patients and 93% of those patients were arrhythmia
free 6 months after LAA isolation (4).
Our study aims to compare the procedure outcome for two different ablation strategies; 1)
standard approach of pulmonary vein isolation extended to the posterior wall down to the
coronary sinus and to the left side of the interatrial septum along with isolation of
superior vena cava and ablation of complex fractionated atrial electrograms (CFAE) in the
atria and coronary sinus, 2) standard approach plus LAA isolation.
Hypothesis: LAA isolation combined with standard ablation procedure enhances the procedural
success rate in non-paroxysmal AF patients undergoing catheter ablation.
Inclusion Criteria:
1. 18-75 years
2. History of PeAF or LSP AF refractory to antiarrhythmic drugs
3. Willing and ability to understand and sign an informed consent
Exclusion Criteria:
1. Reversible causes of AF (hyperthyroidism)
2. Left atrial thrombus
3. Moderate to severe valvular heart disease
4. Contraindication for anticoagulation
5. Life expectancy < 12 months
6. Pregnancy
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