Long-term evaluation of atrial fibrillation ablation guided by noninducibility.
BACKGROUND
Pulmonary vein (PV) isolation and linear lesions are effective in eliminating paroxysmal atrial fibrillation (AF), but linear lesions probably are not required in all patients. Noninducibility of AF has been shown to be associated with freedom from arrhythmia in 87% of patients.


OBJECTIVE
The purpose of this study was to prospectively evaluate the role of noninducibility in guiding a stepwise approach tailored to the patient.


METHODS
In 74 patients (age 53 +/- 8 years) with paroxysmal AF, PV isolation was performed during induced or spontaneous AF. If AF was inducible after PV isolation, one to two additional linear lesions were placed at the mitral isthmus and/or left atrial roof, with the endpoint of noninducibility of AF or atrial flutter. Inducibility (AF/atrial flutter, lasting > or = 10 minutes) was assessed using burst pacing at an output of 20 mA down to refractoriness from the coronary sinus and both atrial appendages.


RESULTS
In 42 patients (57%), PV isolation restored sinus rhythm and rendered AF noninducible. In the 32 patients with persistent or inducible AF after PV isolation, a single linear lesion achieved noninducibility in 20, whereas two linear lesions were required in 12 and resulted in conversion to sinus rhythm and noninducibility in 10. Using this stepwise approach, a total of 69 patients (93%) were rendered noninducible. During follow-up of 18 +/- 4 months, 67 patients (91%) were free from arrhythmia without antiarrhythmic drugs. Repeat procedures were performed in 23 patients: repeat ablation was required to consolidate prior targets in 15 patients (20%), and "new" linear lesions, which were not predicted by inducibility during the index procedure, were required in 8 (11%).


CONCLUSIONS
Noninducibility can be used as an endpoint for determining the subset of patients with paroxysmal AF who require additional linear lesions after PV isolation. This tailored approach is effective in 91% of patients while preventing delivery of unnecessary linear lesions.
Jaïs
Pierre
P
Hôpital Haut-Lévèque and Université Victor Ségalen, Bordeaux II, Bordeaux, France. pierre.jais@chu-bordeaux.fr
Hocini
Mélèze
M
Sanders
Prashanthan
P
Hsu
Li-Fern
LF
Takahashi
Yoshihide
Y
Rotter
Martin
M
Rostock
Thomas
T
Sacher
Frédéric
F
Clementy
Jacques
J
Haissaguerre
Michel
M
D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D012086:Reoperation; D016896:Treatment Outcome
D000925:Anticoagulants