Effect of Epicardial Circumferential Left Atrial Ablation with Pulmonary Vein Isolation in Atrial Fibrillation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

JIANGZhao-lei , YINHang , MEIJu ,  MANan , DINGFang-bao , BAOChun-rong , TANGMin

Department of Cardiothoracic Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200092, P. R. China;

Corresponding author：

MANan, Email: ju_mei63@126.com

Keywords：

Atrial fibrillation; Pulmonary vein isolation; Left atrium; Epicardial

DOI：

10.7507/1007-4848.20160172

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To evaluate the efficacy of the epicardial circumferential left atrial ablation (CLAA) with pulmonary vein isolation (PVI) in curing atrial fibrillation (AF). Methods Thirty experimental pigs, weight from 60-78 kg, were divided into 3 groups with the method of random sampling:a group of AF (AF group, n=10), a group of PVI (PVI group, n=10), and a group of CLAA and PVI (CLAA+PVI group, n=10). AF mode was induced by rapid atrial pacing. After AF was induced, no ablation was performed for pigs in the AF group, PVI was performed for pigs in the PVI group with bipolar radiofrequency ablation clamp, and the CLAA+PVI group underwent CLAA after accepted PVI with bipolar radiofrequency ablation clamp. After ablation, we applied electrovert on AF pigs to recover to sinus rhythm, then we tested the vulnerability and lasting time of AF in all 3 groups. Results All pigs developed a stable and sustained AF by rapid left atrial pacing. The pigs of the PVI group and the CLAA+PVI group successfully underwent ablation with the beating heart. Isolated PVI terminated AF in 3 of 20 pigs, and CLAA with PVI terminated AF in 5 of 8 pigs (15% vs. 62.5%, P=0.022). After all pigs recovered to the sinus rhythm, compared with the AF group (10/10), the incidence of sustained AF by burst pacing was statistically decreased in the PVI group (3/10, P=0.003) and the CLAA+PVI group (0/10, P<0.001). There was no statistical difference between the PVI group and the CLAA+PVI group (P=0.211). There was a statistical decreasing of AF duration in the PVI group (P=0.003) and the CLAA+PVI group (P<0.001) compared with the AF group and there was a statistical decreasing of AF duration in the CLAA+PVI group compared to that of the PVI group (P=0.008). Conclusion Compared with isolated PVI, CLAA+PVI may effectually stop the lasting of AF, restrain the recurrance of AF, and improve the treatment effect of AF.

Citation： JIANGZhao-lei, YINHang, MEIJu, MANan, DINGFang-bao, BAOChun-rong, TANGMin. Effect of Epicardial Circumferential Left Atrial Ablation with Pulmonary Vein Isolation in Atrial Fibrillation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2016, 23(7): 719-723. doi: 10.7507/1007-4848.20160172 Copy

1.	Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemio-logy of atrial fibrillation:a Global Burden of Disease 2010 Study. Circulation, 2014, 129(8):837-847.
2.	McCabe PJ, DeVon HA. Home-based management of patients with atrial fibrillation. Lancet, 2015, 385(9970):752-753.
3.	Healey JS, Connolly SJ, Gold MR, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med, 2012, 366(2):120-129.
4.	Nattel S, Opie LH. Controversies in atrial fibrillation. Lancet, 2006, 367(9506):262-272.
5.	Beyerbach DM, Zipes DP. Mortality as an endpoint in atrial fibrilla-tion. Heart Rhythm, 2004, 1(2 Suppl):B8-18.
6.	Cox JL, Schuessler RB, D'Agostino HJ Jr, et al. The surgical treatment of atrial fibrillation. Ⅲ. Development of a definitive surgical proce-dure. J Thorac Cardiovasc Surg, 1991, 101(4):569-583.
7.	Weimar T, Schena S, Bailey MS, et al. The cox-maze procedure for lone atrial fibrillation:a single-center experience over 2 decades.Circ Arrhythm Electrophysiol, 2012, 5(1):8-14.
8.	Prasad SM, Maniar HS, Camillo CJ, et al. The Cox Maze Ⅲ proce-dure for atrial fibrillation:long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg, 2003, 126(6):1822-1828.
9.	Tilz RR, Chun KR, Schmidt B, et al. Catheter ablation of long-standing persistent atrial fibrillation:a lesson from circumferential pulmonary vein isolation. J Cardiovasc Electrophysiol, 2010, 21(10):1085-1093.
10.	Chao TF, Tsao HM, Lin YJ, et al. Clinical outcome of catheter ablation in patients with nonparoxysmal atrial fibrillation:results of 3-year follow-up. Circ Arrhythm Electrophysiol, 2012, 5(3):514-520.
11.	Latchamsetty R, Morady F. Long-term benefits following catheter ablation of atrial fibrillation. Circ J, 2013, 77(5):1091-1096.
12.	Hori Y, Nakahara S, Kamijima T, et al. Influence of left atrium anatomical contact area in persistent atrial fibrillation. Circ J, 2014, 78(8):1851-1857.
13.	Oral H, Knight BP, Tada H, et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation, 2002, 105(9):1077-1081.
14.	Wolf RK, Schneeberger EW, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclu-sion for atrial fibrillation. J Thorac Cardiovasc Surg, 2005, 130(3):797-802.
15.	Edgerton JR, Jackman WM, Mack MJ. A new epicardial lesion set for minimalaccess left atrial maze:the Dallas lesion set. Ann Thorac Surg, 2009, 88(5):1655-1657.
16.	Edgerton JR, Jackman WM, Mahoney C, et al. Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the "Dallas" lesion set. Heart Rhythm, 2009, 6(12 Suppl):S64-S70.
17.	Betts TR, Jones M, Wong KC, et al. Feasibility of mitral isthmus and left atrial roof linear lesions using an 8 mm tip cryoablation catheter. J Cardiovasc Electrophysiol, 2013, 24(7):775-780.
18.	Jaïs P, Hocini M, Hsu LF, et al. Technique and results of linear abla-tion at the mitral isthmus. Circulation, 2004, 110(19):2996-3002.
19.	Arbelo E, Guiu E, Ramos P, et al. Benefit of left atrial roof linear ablation in paroxysmal atrial fibrillation:a prospective, randomized study. J Am Heart Assoc, 2014, 3(5):e000877.
20.	Mei J, Ma N, Ding F, et al. Complete thoracoscopic ablation of the left atrium via the left chest for treatment of lone atrial fibrillation. J Thorac Cardiovasc Surg, 2014, 147(1):242-246.
21.	Ma N, Ding F, Jiang Z, et al. Totally endoscopic ablation of left atrium via left chest for lone atrial fibrillation. Innovations (Phila), 2012, 7(5):382-384.
22.	Haïssaguerre M, Sanders P, Hocini M, et al. Pulmonary veins in the substrate for atrial fibrillation:the "venous wave" hypothesis. J Am Coll Cardiol, 2004, 43(12):2290-2292.
23.	Michaud GF, John R. Percutaneous pulmonary vein isolation for atrial fibrillation ablation. Circulation, 2011, 123(20):e596-601.
24.	Gill JS. How to perform pulmonary vein isolation. Europace, 2004, 6(2):83-91.
25.	Wyse DG. A critical perspective on the role of catheter ablation in management of atrial fibrillation. Can J Cardiol, 2013, 29(10):1150-1157.
26.	De Maat GE, Pozzoli A, Scholten MF, et al. Long-term results of surgical minimally invasive pulmonary vein isolation for paroxysmal lone atrial fibrillation. Europace, 2015, 18(1):287.
27.	Wilber DJ. Fibroblasts, focal triggers, and persistent atrial fibrillation:is there a connection? Circ Arrhythm Electrophysiol, 2012,5(2):249-251.
28.	Inoue K, Kurotobi T, Kimura R, et al. Trigger-based mechanism of the persistence of atrial fibrillation and its impact on the efficacy of catheter ablation. Circ Arrhythm Electrophysiol, 2012, 5(2):295-301.
29.	Kim YH. Catheter ablation oflongstanding persistent atrial fibrillation. Are we on the right path? Circ J, 2012, 76(6):1299-1306.
30.	Jarman JW, Wong T, Kojodjojo P, et al. Organizational index mapping to identify focal sources during persistent atrial fibrillation. J Cardiovasc Electrophysiol, 2014, 25(4):355-363.
31.	Kim JS, Shin SY, Na JO, et al. Does isolation of the left atrial posterior wall improve clinical outcomes after radiofrequency catheter ablation for persistent atrial fibrillation:A prospective randomized clinical trial. Int J Cardiol, 2014, 181C:277-283.
32.	Nishida K, Sarrazin JF, Fujiki A, et al. Roles of the left atrial roof and pulmonary veins in the anatomic substrate for persistent atrial fibrillation and ablation in a canine model. J Am Coll Cardiol, 2010, 56(21):1728-1736.
33.	Mounsey JP. Left atrial roof ablation is more important than pulmonary vein isolation in terminating persistent atrial fibrillation in a canine model should we perform a left atrial roof line in all atrial fibrillation ablations? J Am Coll Cardiol, 2010, 56(21):1737-1739.
34.	Hocini M, Jaïs P, Sanders P, et al. Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation:a prospective randomized study. Circulation, 2005, 112(24):3688-3696.
35.	Nalliah C, Lim TW, Bhaskaran A, et al. Posterior left atrial isolation for atrial fibrillation in left ventricular diastolic impairment is associated with better arrhythmia free survival. Int J Cardiol, 2015, 184:674-679.
36.	马南,丁芳宝, 陈寅, 等. 左胸径路微创外科治疗孤立性心房颤动. 中华胸心血管外科杂志, 2013, 29(11):692-693.
37.	马南, 姜兆磊, 陈飞, 等. 梅氏微创消融术治疗心房颤动207 例.中国胸心血管外科临床杂志, 2015, 22(11):996-999.

1. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemio-logy of atrial fibrillation:a Global Burden of Disease 2010 Study. Circulation, 2014, 129(8):837-847.
2. McCabe PJ, DeVon HA. Home-based management of patients with atrial fibrillation. Lancet, 2015, 385(9970):752-753.
3. Healey JS, Connolly SJ, Gold MR, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med, 2012, 366(2):120-129.
4. Nattel S, Opie LH. Controversies in atrial fibrillation. Lancet, 2006, 367(9506):262-272.
5. Beyerbach DM, Zipes DP. Mortality as an endpoint in atrial fibrilla-tion. Heart Rhythm, 2004, 1(2 Suppl):B8-18.
6. Cox JL, Schuessler RB, D'Agostino HJ Jr, et al. The surgical treatment of atrial fibrillation. Ⅲ. Development of a definitive surgical proce-dure. J Thorac Cardiovasc Surg, 1991, 101(4):569-583.
7. Weimar T, Schena S, Bailey MS, et al. The cox-maze procedure for lone atrial fibrillation:a single-center experience over 2 decades.Circ Arrhythm Electrophysiol, 2012, 5(1):8-14.
8. Prasad SM, Maniar HS, Camillo CJ, et al. The Cox Maze Ⅲ proce-dure for atrial fibrillation:long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg, 2003, 126(6):1822-1828.
9. Tilz RR, Chun KR, Schmidt B, et al. Catheter ablation of long-standing persistent atrial fibrillation:a lesson from circumferential pulmonary vein isolation. J Cardiovasc Electrophysiol, 2010, 21(10):1085-1093.
10. Chao TF, Tsao HM, Lin YJ, et al. Clinical outcome of catheter ablation in patients with nonparoxysmal atrial fibrillation:results of 3-year follow-up. Circ Arrhythm Electrophysiol, 2012, 5(3):514-520.
11. Latchamsetty R, Morady F. Long-term benefits following catheter ablation of atrial fibrillation. Circ J, 2013, 77(5):1091-1096.
12. Hori Y, Nakahara S, Kamijima T, et al. Influence of left atrium anatomical contact area in persistent atrial fibrillation. Circ J, 2014, 78(8):1851-1857.
13. Oral H, Knight BP, Tada H, et al. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation, 2002, 105(9):1077-1081.
14. Wolf RK, Schneeberger EW, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclu-sion for atrial fibrillation. J Thorac Cardiovasc Surg, 2005, 130(3):797-802.
15. Edgerton JR, Jackman WM, Mack MJ. A new epicardial lesion set for minimalaccess left atrial maze:the Dallas lesion set. Ann Thorac Surg, 2009, 88(5):1655-1657.
16. Edgerton JR, Jackman WM, Mahoney C, et al. Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the "Dallas" lesion set. Heart Rhythm, 2009, 6(12 Suppl):S64-S70.
17. Betts TR, Jones M, Wong KC, et al. Feasibility of mitral isthmus and left atrial roof linear lesions using an 8 mm tip cryoablation catheter. J Cardiovasc Electrophysiol, 2013, 24(7):775-780.
18. Jaïs P, Hocini M, Hsu LF, et al. Technique and results of linear abla-tion at the mitral isthmus. Circulation, 2004, 110(19):2996-3002.
19. Arbelo E, Guiu E, Ramos P, et al. Benefit of left atrial roof linear ablation in paroxysmal atrial fibrillation:a prospective, randomized study. J Am Heart Assoc, 2014, 3(5):e000877.
20. Mei J, Ma N, Ding F, et al. Complete thoracoscopic ablation of the left atrium via the left chest for treatment of lone atrial fibrillation. J Thorac Cardiovasc Surg, 2014, 147(1):242-246.
21. Ma N, Ding F, Jiang Z, et al. Totally endoscopic ablation of left atrium via left chest for lone atrial fibrillation. Innovations (Phila), 2012, 7(5):382-384.
22. Haïssaguerre M, Sanders P, Hocini M, et al. Pulmonary veins in the substrate for atrial fibrillation:the "venous wave" hypothesis. J Am Coll Cardiol, 2004, 43(12):2290-2292.
23. Michaud GF, John R. Percutaneous pulmonary vein isolation for atrial fibrillation ablation. Circulation, 2011, 123(20):e596-601.
24. Gill JS. How to perform pulmonary vein isolation. Europace, 2004, 6(2):83-91.
25. Wyse DG. A critical perspective on the role of catheter ablation in management of atrial fibrillation. Can J Cardiol, 2013, 29(10):1150-1157.
26. De Maat GE, Pozzoli A, Scholten MF, et al. Long-term results of surgical minimally invasive pulmonary vein isolation for paroxysmal lone atrial fibrillation. Europace, 2015, 18(1):287.
27. Wilber DJ. Fibroblasts, focal triggers, and persistent atrial fibrillation:is there a connection? Circ Arrhythm Electrophysiol, 2012,5(2):249-251.
28. Inoue K, Kurotobi T, Kimura R, et al. Trigger-based mechanism of the persistence of atrial fibrillation and its impact on the efficacy of catheter ablation. Circ Arrhythm Electrophysiol, 2012, 5(2):295-301.
29. Kim YH. Catheter ablation oflongstanding persistent atrial fibrillation. Are we on the right path? Circ J, 2012, 76(6):1299-1306.
30. Jarman JW, Wong T, Kojodjojo P, et al. Organizational index mapping to identify focal sources during persistent atrial fibrillation. J Cardiovasc Electrophysiol, 2014, 25(4):355-363.
31. Kim JS, Shin SY, Na JO, et al. Does isolation of the left atrial posterior wall improve clinical outcomes after radiofrequency catheter ablation for persistent atrial fibrillation:A prospective randomized clinical trial. Int J Cardiol, 2014, 181C:277-283.
32. Nishida K, Sarrazin JF, Fujiki A, et al. Roles of the left atrial roof and pulmonary veins in the anatomic substrate for persistent atrial fibrillation and ablation in a canine model. J Am Coll Cardiol, 2010, 56(21):1728-1736.
33. Mounsey JP. Left atrial roof ablation is more important than pulmonary vein isolation in terminating persistent atrial fibrillation in a canine model should we perform a left atrial roof line in all atrial fibrillation ablations? J Am Coll Cardiol, 2010, 56(21):1737-1739.
34. Hocini M, Jaïs P, Sanders P, et al. Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation:a prospective randomized study. Circulation, 2005, 112(24):3688-3696.
35. Nalliah C, Lim TW, Bhaskaran A, et al. Posterior left atrial isolation for atrial fibrillation in left ventricular diastolic impairment is associated with better arrhythmia free survival. Int J Cardiol, 2015, 184:674-679.
36. 马南,丁芳宝, 陈寅, 等. 左胸径路微创外科治疗孤立性心房颤动. 中华胸心血管外科杂志, 2013, 29(11):692-693.
37. 马南, 姜兆磊, 陈飞, 等. 梅氏微创消融术治疗心房颤动207 例.中国胸心血管外科临床杂志, 2015, 22(11):996-999.

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