title: Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination.
abstract: BACKGROUND
  The relative contributions of different atrial regions to the maintenance of persistent atrial fibrillation (AF) are not known.
  
  
  METHODS
  Sixty patients (53 +/- 9 years) undergoing catheter ablation of persistent AF (17 +/- 27 months) were studied. Ablation was performed in a randomized sequence at different left atrial (LA) regions and comprised isolation of the pulmonary veins (PV), isolation of other thoracic veins, and atrial tissue ablation targeting all regions with rapid or heterogeneous activation or guided by activation mapping. Finally, linear ablation at the roof and mitral isthmus was performed if sinus rhythm was not restored after addressing the above-mentioned areas. The impact of ablation was evaluated by the effect on the fibrillatory cycle length in the coronary sinus and appendages at each step. Activation mapping and entrainment maneuvers were used to define the mechanisms and locations of intermediate focal or macroreentrant atrial tachycardias.
  
  
  RESULTS
  AF terminated in 52 patients (87%), directly to sinus rhythm in 7 or via the ablation of 1-6 intermediate atrial tachycardias (total 87) in 45 patients. This conversion was preceded by prolongation of fibrillatory cycle length by 39 +/- 9 msec, with the greatest magnitude occurring during ablation at the anterior LA, coronary sinus and PV-LA junction. Thirty-eight atrial tachycardias were focal (originating dominantly from these same sites), while 49 were macroreentrant (involving the mitral or cavotricuspid isthmus or LA roof). Patients without AF termination displayed shorter fibrillatory cycles at baseline: 130 +/- 14 vs 156 +/- 23 msec; P = 0.002.
  
  
  CONCLUSIONS
  Termination of persistent AF can be achieved in 87% of patients by catheter ablation. Ablation of the structures annexed to the left atrium-the left atrial appendage, coronary sinus, and PVs-have the greatest impact on the prolongation of AF cycle length, the conversion of AF to atrial tachycardia, and the termination of focal atrial tachycardias.
authors.affiliation: Hôpital Cardiologique du Haut-Lévêque, Bordeaux-Pessac, France. jacques.clementy@pu.u-bordeaux2.fr
authors.forename: Michel
authors.initials: M
authors.lastname: Haïssaguerre
authors.forename: Prashanthan
authors.initials: P
authors.lastname: Sanders
authors.forename: Mélèze
authors.initials: M
authors.lastname: Hocini
authors.forename: Yoshihide
authors.initials: Y
authors.lastname: Takahashi
authors.forename: Martin
authors.initials: M
authors.lastname: Rotter
authors.forename: Frederic
authors.initials: F
authors.lastname: Sacher
authors.forename: Thomas
authors.initials: T
authors.lastname: Rostock
authors.forename: Li-Fern
authors.initials: LF
authors.lastname: Hsu
authors.forename: Pierre
authors.initials: P
authors.lastname: Bordachar
authors.forename: Sylvain
authors.initials: S
authors.lastname: Reuter
authors.forename: Raymond
authors.initials: R
authors.lastname: Roudaut
authors.forename: Jacques
authors.initials: J
authors.lastname: Clémenty
authors.forename: Pierre
authors.initials: P
authors.lastname: Jaïs
mesh_terms: D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018709:Statistics, Nonparametric; D016896:Treatment Outcome