Is Empirical Four Pulmonary Vein Isolation Necessary for Focally Triggered Paroxysmal Atrial Fibrillation
Credits:Original Citation :Pak HN, Kim JS, Shin SY, Lee HS, Choi JI, Lim HE, Hwang C, Kim YH. J Cardiovasc Electrophysiol. 2008 May;19(5):473-9.
Reviewed by : Andrea Corrado and Antonio Raviele,"Dell'Angelo" Hospital of Mestre, Venezia, Italy
doi : 10.4022/jafib.v1i1.403
In this study the authors
compared two different ablation strategies for the treatment of paroxysmal
atrial fibrillation (AF): selective isolation of the pulmonary vein triggering AF
(SePVI) versus empirical isolation of all the four pulmonary veins (EmPVI).
Arrhythmogenic vein was identified by immediate recurrence of
AF after cardioversion using infusion of isoproterenol as provocative manoeuvre.
The exclusion criteria were as follows: non-proxysmal AF, non detectable foci,
non-PV foci, multiple PV foci or presence of structural heart disease. After
exclusion of those, 77 patients out of 260 patients that underwent AF ablation,
were enrolled in the study. After more than 3 years of follow up, 38% of
patients treated with SePVI experienced AF recurrences versus 26% of patients treated
with EmPVI (p = ns). Very late recurrences (later that 1 year) had a tendency
to be more common in the SePVI group (19%) than in the EmPVI group (6%) (p =
ns). A redo ablation was performed in most of patients that experienced
recurrences. Fifty-four percent of patients in the SePVI group exhibited a
reconnection of PV previously disconnected, 38% exhibited triggers arising from
the ipsilateral but not ablated PV and 8% from the controlateral PV. On the other
hand, a reconnection of PV was demonstrated in 37% of patients in the EmPVI
group, triggers arising from ipsilaterl PV in 25% of patients and from the
controlateral PV in 38% of patients.
Given these findings
authors conclude that there was non statistically significant difference in the
success rate between the two ablation strategies.
Authors suggest the
sharable idea that a minimal approach may be applicable to a subgroup of
younger and healthier patients manifesting paroxysmal AF clearly initiated by
limited triggers. However, the main limitation of the study is that the resulting
absence of statistically significant difference in success rate is certainly due
to the small size of study population. In fact, increasing the number of
patients, the same 12% of absolute difference would become statistically
significant. Therefore, how to select patients that can be treated
appropriately with a limited strategy remain to be clarified.