Propagation ANalysis for Arrhythmogenic Conduction Elimination to Prevent Atrial Flutter and Fibrillation (PANACEA-AF)

Catheter ablation (CA) is a class 1 indication for patients with symptomatic drug-refractory
atrial fibrillation (AF). With standard pulmonary vein isolation (PVI), the success rate
ranges from 60-80% in patients with paroxysmal AF. Despite PVI, certain patients have
recurrent AF and often require a repeat ablation procedure.

There is no standard ablation strategy for patients who undergo repeat ablation for recurrent
AF. The largest randomized trial to date comparing ablation strategies found that the
addition of LA roof and mitral isthmus ablation lines or ablation of LA ganglia was no better
than standard PVI. Moreover, the addition of ablation lines in the LA, if not complete, may
be pro-arrhythmic and lead to the development of LA AFL, which is often more symptomatic that
AF itself.

Ultra-high density mapping during sinus rhythm allows for rapid creation of isochronal late
activation maps (ILAM) in patients with ventricular tachycardia. To date, creating ILAM of
the LA has not been reported and it is not known whether additional ablation in these areas
improves freedom from all atrial tachyarrhythmias at 1 year follow-up. Moreover, ablation at
the deceleration zones and/or gaps identified using ultra-high density mapping is a promising
strategy to improve ablation success and decrease the potential for recurrent AF.

The rationale of the study is two-fold.

1. This study would be the first to report ILAM in the LA and confirm that the diseased LA
may behave similarly to the diseased left or right ventricle.

2. Ablation of gaps and/or deceleration zones in the LA would be a novel approach to treat
patients with recurrent AF after initial PVI, and if successful, provide another
strategy to treat these refractory problems.

Co-PIs:

Hemal Nayak, MD Guarav Upadhyay, MD Andrew Beaser, MD Zaid Aziz, MD

Inclusion Criteria:

- Patients at least 18 years of age

- Re-do AF ablation with history of PVI

Exclusion Criteria:

- Inability of patient capacity to provide consent for themselves either due to medical
or psychiatric comorbidity

- Recent stroke within 6 months of planned procedure

- Inability to take oral anticoagulation